1.) How long have you been established at your current office location?
If the office is to be established in the future, state the date you anticipate first holding office hours:
How many patients are seen in your office per month?
Are you currently accepting new patients?
2.) Are you or will you be a member of or associated with a practice group?
Please identify the practice group and other physicians/practitioners in the group?
3.) In what specialties are you or have you been Board Certified and year of certification?
4.) Have you ever been denied privileges at a hospital?
5.) Have you ever been disciplined, lost privileges or voluntary relinquished privileges?
6.) Has action limiting, restricting or withdrawing your license ever occurred?
7.) Are you employed by or associated with a Hospital, Hospital System, Health Maintenance Organization or similar organization to care for and treat patients?
If your response is in the affirmative, please state the name and address of the Hospital et al. by whom you are employed or with which you are associated:
8.) Expressed as a percentage, state the extent of your practice you anticipate at hospitals?
At which hospitals do you currently have staff privileges and percentage of admissions to each?
9.) With whom do you share hospital and skilled nursing facility coverage, if applicable?
How often do you provide coverage?
10.) Do you see patients regularly at a skilled nursing facility?
If your response is in the affirmative please state the name and address of those facilities: