Provider Disclosure Form
Thank you for expressing interest in CarePoint Health. Please take a few minutes and complete our Provider Disclosure Form. Completion of this form is required for all providers interested in employment with CarePoint Healthcare.
Personal Information
Full Name:
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First Name
Middle Name
Last Name
Phone Number:
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E-mail:
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Type of Provider
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Physician
Adavanced Practice Provider (PA or NP)
Specialty:
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Are you legally authorized to work in the United States? (Proof of employment eligibility will be required upon employment)
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Yes
No
Do you understand that you will have to complete a urine drug screen within 14 days of contract signature as part of the pre-employment process?
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Yes
No
Education & Training Information
Professional Or Medical School Attended:
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Please include city and state.
Degree:
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Please Select
MD
DO
ARNP
PA
Year of Program Start:
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Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
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Year of Program End:
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2024
2023
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Residency Attended:
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Please include city and state.
Year of Program Start:
*
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
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Year of Program Completion:
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2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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Fellowship Attended:
Please include city and state.
Year of Program Start:
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1951
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1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Year of Program Completion:
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
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Board Certification:
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Board Certified
Board Eligible
Other - Please Explain Below & Provide Supporting Documentation
Explanation:
Please Provide Written Plan With Specific Dates on Obtaining Board Certification
Upload Supporting Documentation
Board Certification Specialty:
Enter all board certifications if more than one.
NPI#:
DEA#:
List Any Previous Names or Other Names You May Be Affiliated or Licensed Under:
*
If none, please type "none"
State Medical Licensing
List all states where you are currently licensed or have held a license to practice medicine.
State 1:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License #:
License Active:
Yes
No
State 2:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License #:
License Active:
Yes
No
State 3:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License #:
License Active:
Yes
No
If Additional State Licenses Are Held Please Enter Information Here:
Please Answer Each of The Following Questions to the Best of Your Knowledge
1). Any there any gaps in your education, training, or employment?
*
Yes - Please Explain Below
No
Explanation:
If yes, please provide details explaining any gaps during your professional or medical school, residency, fellowship, practice, etc.
2). Have there ever been or are there currently any professional liability claims, suits, judgments, settlements or arbitration proceedings involving you, including your time in training programs (APP rotations, internship, residency, fellowship, etc.)?
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Yes - Please Explain Below & Provide Supporting Documentation
No
Explanation:
If yes, please provide details of any verbal or documented agreements made directly with patient(s) for treatment/care, that resulted from dismissal of a malpractice claim or were made outside of the court system.
Upload Supporting Documentation
3). Are you aware of any incidents or occurrences that have not yet resulted in a claim or suit but could in the future?
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Yes - Please Explain Below & Provide Supporting Documentation if Appropriate
No
Explanation:
If yes, please provide details of the incident or occurrence
Upload Supporting Documentation (if appropriate)
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4). Are there any entries in the National Practitioners Database related to you of which you are aware?
*
Yes - Please Explain Below & Provide Supporting Documentation
No
Explanation:
If yes, please provide details of NPDB entries that are related to you. Please run a self-inquiry on the NPDB and upload the results below.
Upload NPDB Self Inquiry Report
5). Are you currently or have you ever been the subject of an adverse action by a hospital and/or medical staff, professional organization, professional licensing body, state or federal agency? Adverse actions include, but are not limited to: Denial of privileges, formal discipline (including a letter of admonition), suspension, fines, investigation for cause, sanction, request to withdrawal from participation or subject to other probationary conditions up to and including termination?
*
Yes - Please Explain Below & Provide Supporting Documentation
No
Explanation:
If yes, please explain and provide all related documentation
Upload Supporting Documentation
6). Have you ever been sanctioned, suspended, excluded or otherwise determined to be ineligible from participating in a federal or state health care program such as Medicare or Medicaid?
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Yes - Please Explain Below & Provide Supporting Documentation
No
Explanation:
If yes, please explain and provide all related documentation
Upload Supporting Documentation
7). Have you ever been convicted of, pled guilty, or pled non contendere to a felony or misdemeanor, other than a traffic violation?
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Yes - Please Explain Below & Provide Supporting Documentation
No
Explanation:
If yes, please explain and provide all related documentation
Upload Supporting Documentation
8). CarePoint Healthcare is a drug free work environment. The Drug-Free Workplace Act (DFWA) requires federal contractors to prohibit the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance by employees in their workplace as a condition of employment. Under federal law, marijuana remains an illegal drug and, therefore, the use of marijuana constitutes an illegal act. Because the use of marijuana remains "illegal" under federal law, an employer is not required to accommodate employees who request the use of marijuana, regardless of the law of the state. As a condition of employment, drug use, including marijuana is prohibited. By clicking yes, I am attesting to the fact that I do not and will not use any illegal substances.
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Yes - I agree to abide by CarePoint Healthcare's Illegal Drug Usage Policy
No - I DO NOT agree to abide by CarePoint Healthcare's Illegal Drug Usage Policy
Explanation:
If yes, please explain and provide all related documentation
Upload Supporting Documentation
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. CarePoint Healthcare has the option to 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 decide against moving forward with the recruitment, employment, sub-contract agreement or locums services, all provider recruitment disclosure application materials will be properly discarded.
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