Provider Disclosure Form

Provider Disclosure Form

Provider Disclosure Form Template - Specified agreement. Useful for companies that need to keep a track of their providers and the terms and conditions of the business. Form Preview
Centura Health - Provider Disclosure Form - Ken LeBlanc
  • Provider Recruitment Disclosure Form

  • Personal Information

  • Current Practice Information

  • List All States Where You Are Currently Licensed or Have Held a License to Practice Medicine

  •  -  - Pick a Date
  •  -  - Pick a Date
  •  -  - Pick a Date
  • Please Answer Each of The Following Questions to the Best of Your Knowledge

  • Consent & Authorization

  • I consent to and authorize the inspection of appropriate records and documents that may be material to an evaluation of my qualifications and my ability to carry out clinical privileges / services / participation. CHPG will primary source verify the above information via: Query / NPDB; DEA / NTIS; Colorado License (if applicable) / DORA; Board Certification / CertiFACTS, OIG, Medicare Opt Out. I certify the above information is true and complete. Any misstatements or omissions (whether intentional or unintentional), may constitute cause for denial of continuation of recruitment, employment, sub-contract agreement or locums services. Should either party decides against moving forward with the recruitment, employment, sub-contract agreement or locums services, all provider recruitment disclosure application materials will be properly discarded via secure shredding.

  • Clear