Candidate Authorization | Adaptive Medical Partners

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Candidate Authorization

Release and Authorization

Name*
First Last
Recruiter Name*
Title

(MD, DO, other)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Month
Day
Year
Personal Photo
Accepted file types: jpg, gif, png, Max. file size: 20 MB.
NPI#
DEA#
Have you been subject to any claims for medical mal-practice liability or medical litigation? Are there any cases of medical liability pending? Please include a detailed description of each claim.*
- Yes
- No
Medical Claim Description
Have you ever involuntarily surrendered medical staff privileges? Have you ever had your medical staff privileges denied, suspended or diminished in any way from any state board or hospital agency?*
- Yes
- No
Include Details
Have you ever been subject to a complaint or hearing, or been requested to appear before any licensure agency?*
- Yes
- No
Include Details
Have you had any insurance carriers cancel or refuse coverage because of elevated risk assessments?*
- Yes
- No
Include Details
Have you ever been subject to any criminal or civil litigation or, are there any causes of this sort currently pending? Please include details of litigation.*
- Yes
- No
Description
Are you board certified?
- Yes
- No
By what board?
In what states do you currently hold an active license to practice medicine?
License # State
Please provide complete contact information for at least four (4) professional references.
Contact 1
Name
Prefix First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Title
Facility
Relationship
Contact 2
Name
Prefix First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Title
Facility
Relationship
Contact 3
Name
Prefix First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Title
Facility
Relationship
Contact 4
Name
Prefix First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Title
Facility
Relationship
By selecting the "Yes" button below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document and all information contained within is accurate to the best of your knowledge and you are authorizing Adaptive Medical Partners (AMP) to perform a basic background check which will accompany the dossier information (prepared by Adaptive Medical Partners). Furthermore, I authorize AMP to share said information with representatives of the prospective practice opportunities discussed with you.*
- Yes
Without complete information - prospective practice representatives may decline to schedule interview.
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Adaptive Medical Partners

3229 Premier Drive, Suite 200
Irving, TX 75063

(888) 885-5009
inquire@adaptivemedicalpartners.com

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