Physician Panel Application

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Physician Panel Application

Name

Tax ID

Practice Name

Primary Practice Address where IME's are conducted

Mailing Address

Additional IME Locations

Office Phone Number

Fax Number

Scheduling Contact & Email

Current Medical License

PLEASE ATTACH: CURRENT FEE SCHEDULE, W9, SAMPLE REPORT, MEDICAL LICENSE, BOARD CERTIFICATION, LIABILITY INSURANCE, CURRENT CV

Has your license to practice in any jurisdiction ever been surrendered, limited, suspended, revoked, placed on probation, involuntarily relinquished or otherwise had conditions placed upon it?

Yes No

Have your privileges at any hospital or other healthcare facility ever been suspended, diminished, revoked or not renewed?

Yes No

Have you been refused a requested specialty medical or professional society membership?

Yes No

Have you ever been asked to resign or not renew a specialty,medical or professional society membership?

Yes No

Have you ever been refused medical malpractice insurance or been refused renewal of your medical malpractice insurance?

Yes No

In the last 5 years, have you had an alleged medical malpractice action filed against you that resulted in an out-ofcourt settlement, or judgment against you?

Yes No

Do you have any alleged medical malpractice actions filed against you pending or have suspicion of an imminent such action against you?

Yes No

Have you ever been convicted of a felony?

Yes No