Physician's Referral Line, Athens, GA, Physician Membership Application

caap-coalitions or athens area physicians

Physician
Membership Application

Last Name:	First Name:	Middle Initial:
Alias:	Title:	Suffix:
Social Security Number:
Birth Information
Gender:	Birthdate:
City:	State:	Country:
Primary Business Office
Practice:	Name:
Address:
City:		State:
Zip:	Phone:	Emergency Number:
Fax:	Tax ID Number:
Medical or Professional School
School:
State:	Country:	Start Date:
Grad Date:	Finish Date:	Degree:
Board Certification
Primary Specialty:	Board Certified in Primary Specialty:	Board Description:
Date Issue:	Date Expired:
Areas of Concentration:
Primary Admitting Facility
Name:
Address:
Privileges:	Start Date:	Finish Date:
Contact:	Code:
Liability Carrier - Current
Carrier Name:		Policy Number:
Contact Number:	Effective Date:	Expiration Date:
Specialty
Licenses One State:	Lic. Num:	Exp Date:
Status:
DEA Num:	Exp. Date:

1.	Has your license to practice in any jurisdiction ever been denied, restricted, limited suspended or revoked, either voluntarily or involuntarily?	no yes
2.	Have you ever been reprimanded by any state licensing agency, or are you currently under investigation by any state licensing agency with the respect to your license to practice?	no yes
3.	Has your DEA or state controlled substances registration ever been restricted, limited, suspended or revoked, either voluntarily or involuntarily?	no yes
4.	Are you currently under any investigation with respect to your DEA or state controlled substances registration?	no yes
5.	Have you ever been denied hospital privileges or have you ever had any hospital privileges revoked, suspended, reduced or non-renewed?	no yes
6.	Have you ever voluntarily relinquished or voluntarily limited any hospital privileges?	no yes
7.	Have any disciplinary proceedings ever been instituted against you or are any disciplinary actions now pending with respect to your hospital privileges?	no yes
8.	Have you ever been reprimanded, censured, excluded, suspended, denied or disqualified from participating in Medicare, Medicaid or any other governmental or quasi-governmental health-related program?	no yes
9.	Have any complaints ever been filed against you with a medical society or licensing authority?	no yes
10.	Are there any professional liability claims currently pending against you?	no yes
11.	Have any professional liability claim settlements of any kind been paid by you or paid on your behalf in the last five years?	no yes
12.	Have any professional liability judgments ever been entered against you in the last five years?	no yes
13.	Have you ever had your professional liability insurance coverage canceled by your carrier?	no yes
14.	Have you ever been convicted of a crime (other than a minor traffic offense) or do you have any criminal charges pending other than for minor traffic offenses?	no yes
15.	Have you ever been refused participation in a network or managed care organizations (HMO or PPO) or been disciplined by or terminated from such a plan or organization?	no yes
16.	Has any information pertaining to you ever been reported to the National Practitioner Data Bank (NPDB)?	no yes
17.	Do you have a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? If the answer is Yes, please answer questions 18 and 19.	no yes
18.	Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program?	no yes
19.	Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting or manner in which you have chosen to practice?	no yes
20.	Do you use any chemical substance(s) which might in any way impair or limit your ability to practice medicine with reasonable skill and safety?	no yes
21.	Are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?	no yes
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(706) 549-DOCS
Physician Referral Service
CAAP • 2350 Prince Avenue • Suite 9 • Athens, GA 30606
Phone: 706-208-1990 • Fax: 706-208-1989

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