Urgent Care Advanced Practice Provider

First name*

Last name*

Email address*

Location

Phone number*

Resume*

Please provide 2-3 references with email addresses and phone numbers:*

College/University*

Desired Salary Range*

Earliest Start Date*

Work Weekends*

Work Evenings*

Languages Spoken*

If hired, can you provide proof that you are eligible to work in the United States?*

What type of employment are you looking for? Please check all that apply.*

Level of Healthcare Experience*

Location available to work: (Choose all that apply)*

Please explain any gaps in your employment history:*

Have you ever previously worked for NowCare or Bayview?*

Did you rotate through any Bayview practices during your training? If so, name the practice(s) and the date(s) of your rotation below. If this does not apply to you, please type N/A in the box.*

Do you have a relative working for MMSI, NowCare, or Bayview? If yes, please provide their name.*

What type of position are you most interested in? (i.e. Urgent Care, Hospitalist, Primary Care, Specialty) Please list your first and second choice in the box below.*

Have you ever been charged or convicted in a court of law for an offense other than a minor traffic violation? If yes, please explain below.*

Have you ever been involved in any federal or state investigations concerning fraud or abuse? if yes, please email a statement to [email protected].*

Have you ever or are you currently excluded from providing services to patients that are covered under any federally funded health-care plan, including Medicare, Medicaid, & all other federal health-care programs? If yes, please email a statement to [email protected].*

Have you ever had a board inquiry or any regulatory inquiry? If yes, please explain below.*

Have you ever been named in a medical malpractice case? If yes, please explain below.*

Have you ever been charged or convicted of a felony or crime of moral turpitude as defined by any state in the U.S.? If yes, please explain below.*

Is your current and/or previous license(s) in good standing? If no, please explain below. If you do not currently have a license, please type N/A in the box below.*

Is your current DEA in good standing? If no, please explain below. If you do not currently have a DEA, please type N/A in the box below.*

Human Check*