<p> Resident Preceptorship Fellowship Preceptorship</p><p>While we encourage this academic activity of our staff physicians, it is necessary for medical and legal purposes to have certain information on file prior to you coming to ProHealth Care Inc. For this reason, we ask that you complete this form and return prior to starting your rotation. You may return via fax to 262-928-7175.</p><p>Name: ______First Middle initial Last</p><p>It is our understanding that you will be acting in the capacity of:</p><p>Resident</p><p>Fellowship</p><p>Dr. ______located at ______from ______to ______. (Start date) (End date)</p><p>The Resident and/or Fellow will render service to patients only under the direct supervision of the preceptor. He/she will not perform procedures independently and orders written by the Resident/Fellow must be signed by a member of the Hospital Medical Staff.</p><p>PROFESSIONAL INFORMATION (Please include all states which you are currently or have been licensed in)</p><p>License Number(s) ______State(s) ______</p><p>Date Issued ______Expiration Date ______</p><p>DEA # ______Date Issued ______Expiration Date______</p><p>Are you Board Certified ______Which Specialty ______</p><p>Date of Certification ______Expiration Date______PLEASE PRINT </p><p>PERSONAL FORMATION</p><p>Name______F / M First Middle initial Last Sex</p><p>Home Address ______</p><p>City, State, Zip______</p><p>Home Phone #______Cell Phone #______Date of Birth ______</p><p>Email address ______Social Security # ______</p><p>MEDICAL EDUCATION</p><p>Name of University/College ______</p><p>Address ______</p><p>City, State, Zip ______</p><p>Dates Attended ______to ______Degree______(Start Date) (End Date) </p><p>INTERNSHIP/RESIDENCY EDUCATION</p><p>Name of University/College ______</p><p>Address ______</p><p>City, State, Zip ______</p><p>Dates Attended ______to ______(Start Date) (End Date) </p><p>Anticipated Graduation Date ______Anticipated Degree ______</p><p>What year are you in? 1 2 3 4 5 Graduation date______</p><p>FELLOWSHIP EDUCATION</p><p>Name of Training Hospital / School ______</p><p>Street Address ______</p><p>City, State, Zip ______</p><p>Specialty ______What year are you? 1 2 3 4 </p><p>Dates Attended ______to ______Page 2 Start Date End Date </p><p>Graduation date ______</p><p>OTHER INFORMATION Please read and answer the following questions carefully. If answered Yes to question, please explain.</p><p>1. Has your narcotic license ever been restricted in any manner or have you voluntarily or involuntarily relinquished or restricted your privilege to prescribe controlled substances, or is any action pending that might result in such restriction? Yes No N/A</p><p>2. Has your license to practice in any jurisdiction ever been denied, restricted, suspended, reduced or not renewed? Have you been reprimanded or censured in any way by a licensing agency? Is any action pending that might result in such modification or censure? Yes No N/A</p><p>3. Have you ever relinquished, voluntarily or involuntarily your license to practice medicine in any jurisdiction? Yes No N/A</p><p>4. Have your privileges or membership at any hospital or institution ever been denied, suspended, reduced or not renewed? Is any action pending that might result in such action? Yes No N/A</p><p>5. Have you ever relinquished, voluntarily or involuntarily any or all of your privileges at any health care institution? Yes No N/A</p><p>6. Have you ever been denied membership, or renewal thereof, or been disciplined by any medical organization, e.g. AMA, a state or local medical society or any medical specialty society, or is any action pending that might result in such occurrence? Yes No N/A</p><p>7. Is your physical or mental health such that it may impair your ability to practice within the scope of the privileges you have applied? Yes No N/A</p><p>8. Are you being or have you ever been treated for alcoholism or substance abuse? Yes No N/A</p><p>9. Do you have any felony or misdemeanor charges pending or have you ever been convicted of charges other than a traffic violation? Yes No N/A</p><p>10. Is there now pending against you any legal action before a court or arbitration panel or have you ever been found liable or mad an out-of-court settlement in a medical malpractice suit or proceeding, or has such a settlement been made on your behalf by any insurance carrier? (If yes, please prepare a separate sheet stating the date the suit started, the name and location of the court or compensation panel before which the matter was commenced, the names of all parties to the proceeding, disposition of the case and basic information pertaining to the substance of the allegations made in the proceeding.)</p><p>Page 3 Yes No N/A</p><p>11. Have you ever been refused medical liability insurance or has any such policy been cancelled or specially rated, or is there any pending action that might result in one of the above consequences? Yes No N/A</p><p>Page 4 Confirmation of Credentials for Preceptorship</p><p>This form must be completed by the Director of the Accredited Residency/Fellowship Program to which the Resident/Fellow is responsible, and signed by the Director.</p><p>______whose “Resident/Fellow Information Form” accompanied (Resident/Fellow Name) this document, is a bona fide Resident/Fellow serving in an approved Residency/Fellowship program of______and His/Her primary training site is______.</p><p>Working under the direction of Dr. ______(Preceptor’s Name) at ProHealth Care Inc. will constitute a legitimate extension of the education experience provided by this program and would comply with the rules thereof. Medical Liability coverage for the above named </p><p>Resident/Fellow provided under Policy #______. This Resident/Fellow will work under the direct supervision of the above-named Preceptor(s) from______to ______. (Start date) (End date)</p><p>Any orders written by this Resident/Fellow will be signed by an appropriately-privileged member of the </p><p>Medical Staff prior to implementation. </p><p>Life Safety Code Acknowledgement</p><p>I hereby acknowledge that I have received the Life Safety Code Information card which is given out with the I.D. Badge.</p><p>I understand and agree to the above statements.</p><p>I hereby certify that all of the information completed is accurate, complete and true. </p><p>______Resident Signature Date</p><p>______Print Name</p><p>Page 5</p>