Instructions:

1. Information must be typed or printed.

2. All questions must be answered, and forms must be signed where indicated.
3. If there is a break in the continuity of your medical education, internship, residency, hospital
affiliations, medical practice, etc., please explain.
4. If more space is needed please attach additional sheets and reference the questions being answered.

SECTION I: GENERAL INFORMATION

Name: ________________________________________________ Date: _______________

(Full legal name)

List all names under which you have been licensed, enrolled, or also known as:

____________________________________________________________________________

____________________________________________________________________________

Mailing Address: ______________________________________________________________

City: ____________________________ State: ______________ Zip: ____________________

Phone number: _______________________________________________________________

Date of Birth: _______________________ SS#: ____________________________________

Place of Birth: ___________________________ Citizenship: ___________________________

If not a citizen of the United States, please give the status and expiration date of your Visa:

____________________________________________________________________________

EMERGENCY CONTACT:

Name: _______________________________ Phone Number: __________________________

Address: ____________________________________________________________________
(Street, City, State, ZIP)

SECTION II: EDUCATION

Diplomas: (Please submit copies of all diplomas and/or certificate of completion)

UNDERGRADUATE/ PRE-MEDICAL:
School Name: _________________________________________ Major: _________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)
Degree Received: ___________________ Dates Attended (start/ end): ___________________
(month/ year)
Date Graduated (month/ year): _________________
Application of Appointment 1
School Name: _________________________________________ Major: _________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)
Degree Received: ___________________ Dates Attended (start/ end): ___________________
(month/ year)
Date Graduated (month/ year): _________________

GRADUATE/ MEDICAL:
School Name: _________________________________________ Major: _________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)
Degree Received: ___________________ Dates Attended (start/ end): ___________________
(month/ year)
Date Graduated (month/ year): __________________

School Name: _________________________________________ Major: _________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)
Degree Received: ___________________ Dates Attended (start/ end): ___________________
(month/ year)
Date Graduated (month/ year): ___________________

ECFMG # ______________________________________ Date Issued: __________________

(Please submit copy of ECFMG certificate)

RESIDENCY PROGRAMS:

Institution: ___________________________________________________________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)
Program Supervisor: ___________________________________________________________

Degree Received: ________________ Date(s) Attended (start/end): _____________________

(month/ year)
Date Graduated (month/ year): ______________________

Institution: ___________________________________________________________________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)

Program Supervisor: ___________________________________________________________

Degree Received: ________________ Date(s) Attended (start/end): _____________________

(month/ year)
Date Graduated (month/ year): _______________________

Application of Appointment 2
Were you the subject of any disciplinary actions during your attendance at any of the
Institution in this section? If yes, attach an explanation…………………………….…….YES NO

SECTION III: MEDICAL LICENSURE/ CERTIFICATION

LICENSES: (Please submit copies of all licenses)
Fill in all blanks, or mark through if it does not apply to you.

Type: ________________ State: ____________ Number: ______________

Issue Date: ___________ Expiration Date: ___________

Type: ________________ State: ____________ Number: ______________

Issue Date: ___________ Expiration Date: ___________

Type: ________________ State: ____________ Number: ______________

Issue Date: ___________ Expiration Date: ___________

CDS Registration Certification Number: _____________________ Expiration Date: _________

DEA Registration Number: __________________________ Expiration Date: _______________

Does your DEA/State Controlled Substance Number reflect schedules 2, 2N, 3, 3N, 4 and 5?
Yes ______ No ________

If no, please explain: ___________________________________________________________

NPI # ______________________________

Medicare ID Number_______________________ Medicaid Number _____________________

SECTION IV: PROFESSIONAL LIABILITY

Please submit a copy of your insurance certificate.
Insurance Company: ___________________________________________________________
Policy Limits: __________________ Per Occurrences $__________ Aggregate $___________

Complete Address: ____________________________________________________________

(Street, City, State, ZIP)

Agent: _____________________ Policy Number: ______________ Expiration Date: ________

Prior Carriers: ________________________________________________________________

1. Have any professional liability lawsuit been filed against you during the past ten years
(including those closed)……………………………………………………….…….YES NO

2. Are there any now pending?.............................................................................YES NO

Application of Appointment 3
 3. Has any judgement, payment of claim, or settlement ever been made against you in any
professional liability cases?.............................................................................. YES NO

4. Has any judgement or payment of claim or settlement amount exceeded the limits of this
coverage?......................................................................................................... YES NO

5. Have you ever been denied professional insurance, or has your policy ever been
cancelled?........................................................................................................ YES NO
If yes, please provide a list for each instance which indicates the date the suit was started, the name and location of
the court, the names of the parties, a brief description of the amount and nature of the claim, and the current status
on a separate sheet.

SECTION V: OCCURRENCES
Please answer the following questions. If the answer is YES to any of the following, please give detailed explanation
on separate sheet.

1. Has your license to practice in any jurisdiction ever been denied,

suspended, restricted, revoked, limited, canceled, and/or subject to
probation either voluntarily or involuntarily, or has application for license
ever been withdrawn?.............................................................................................. YES NO

2. Have you ever been reprimanded and/or fined, been the subject of a complaint,
and/or have you been notified in writing that you have been investigated
as the possible subject of a criminal, civil, or disciplinary action by any
state or federal agency that license providers?....................................................... YES NO

3. Have you lost any board certification(s), and/or failed to rectify

(may not apply)?...................................................................................................... YES NO

4. Have you been examined by a Capital Certifying Board but failed

to pass (may not apply)?.......................................................................................... YES NO

5. Has any information pertaining to you, including malpractice judgements

and/or disciplinary action, ever been reported to the National Practitioner
Data Bank (NPDB) or any other practitioner data bank?.......................................... YES NO

6. Has your federal DEA number and/ or state controlled substances

license been restricted, limited, relinquished, suspended, or revoked,
either voluntarily or involuntarily, and/or have you ever been notified in
writing that you are being investigated as the possible subject of a criminal
or disciplinary action with respect to your DEA or controlled substance
registration?............................................................................................................. YES NO

7. Have you, or any of your hospital or ambulatory surgery center privileges

and/or memberships been denied, revoked, suspended, reduced,
placed on probation, proctored, placed under mandatory consultation,
or non-renewed?....................................................................................................... YES NO

8. Have you voluntarily or involuntarily relinquished or failed to seek renewal

of your hospital or ambulatory surgery center privileges for any reason?............... YES NO

Application of Appointment 4
9. Have any disciplinary actions or proceedings been instituted against you
and/or any disciplinary actions or proceedings now pending with
respect to your hospital or ambulatory surgery center privileges and/or
your license?............................................................................................................ YES NO

10. Have you ever been reprimanded, censured, excluded, suspended, and/or
disqualified from participating or voluntarily withdrawn to avoid an
investigation, in Medicare, Medicaid, CHAMPUS, and/or any other
governmental health-related programs?.................................................................. YES NO

11. Have Medicare, Medicaid, CHAMPUS, PRO authorities, and/or any other
third-party payors brought charges against you for alleged inappropriate
fee and/or quality-of-care issues?............................................................................. YES NO

12. Have you been denied membership and/or been subject to probation,
reprimand, sanction, or disciplinary action, or have you ever been notified
in writing that you are being investigated as the possible subject of a
criminal or disciplinary action by any health care organization, e.g., hospital,
HMOP, PPO, IPA, PHO, professional group, or society health care entity,
or health care plan prior to a final decision to avoid a professional review or
an adverse decision?................................................................................................ YES NO

13. Have you withdrawn an application or any portion of an application for

appointment or reappointment for clinical privileges or staff appointment
or for license or membership in an IPA, PHO, professional group, or society,
health care entity, or health care plan prior to a final decision to avoid a
professional review or an adverse decision?........................................................... YES NO

14. Have you been charged with or convicted of a crime (other than a minor
traffic offense) in this or any other state or country and/or do you have
any criminal charges pending other than minor traffic offenses in this state
or any other state or country?................................................................................... YES NO

15. Have you been the subject of a civil or criminal or administrative action or
been notified in writing that you are being investigated as the possible
subject at a civil, criminal, or administrative action regarding sexual
misconduct, child abuse, domestic violence, or elder abuse?................................. YES NO

16. Have you had a refusal or cancellation of professional liability coverage?.............. YES NO

If yes to any of the above, please explain on a separate sheet.

CONDITIONS OF APPLICATION:
By applying for clinical privileges, I hereby signify my willingness to appear for interviews in regard to my
application, and authorize “Trenton Medical Center, Inc. dba Palms Medical Group”, its medical staff, and
their representatives to consult with members of management and members of medical staffs of other
hospitals or institutions with which I have been associated and with others, including past and present
malpractice insurance carriers, who may have information bearing on my professional competence,
character, and ethical qualifications. I hereby further consent to inspection by “Trenton Medical Center,
Inc. dba Palms Medical Group”, its medical staff, and its representatives of all records and documents,
including medical and credential records at other hospitals, which may be material to an evaluation of my
qualifications for staff membership. I hereby release from liability all representatives of “Trenton Medical
Center Inc. dba Palms Medical Group” and its medical staff, in their individual and collective capacities,
for their acts performed in good faith and without malice in connection with evaluating my application and
my credentials and qualifications, and I hereby release from any liability any and all individuals and
organizations who provide information to “Trenton Medical Center, Inc dba Palms Medical Group” or
Application of Appointment 5
members of its medical staff in good faith and without malice concerning my professional competence,
ethics, character, and other qualifications for staff appointment and clinical privileges. I hereby consent to
the release of information by other hospitals, other medical associations, and other authorized persons,
on request, regarding any questions “Trenton Medical Center, Inc. dba Palms Medical Center” may have
concerning me as long as such release of information is done in good faith and without malice, and I
hereby release from liability and hold harmless “Trenton Medical Center, Inc dba Palms Medical Center”
and any third party for so doing. I understand and agree that I, as an applicant for clinical privileges, have
the burden of producing adequate information for the proper evaluation of my professional competence,
character, ethics, and other qualifications and for the resolution of any doubts about such qualifications.

By accepting appointment and/or reappointment to the medical staff at “Trenton Medical Center, Inc dba
Palms Medical Group”, I hereby acknowledge and represent that I have read and am familiar with the
bylaws, rules, and regulations of “Trenton Medical Center, Inc. dba Palms Medical Group”, as well as the
principles, standards, and ethics of the national, state, and local associations and state law and
regulations that apply to and govern my specialty and/ or profession, which are the “Governing
Standards.” I further agree to abide by such further Governing Standards as may be enacted from time to
time.

In addition, I agree to notify “Trenton Medical Center, Inc. dba Palms Medical Group” of any circumstance
that would change my status in licensure, DEA, Medicare participation, liability insurance coverage, board
certification status, or hospital privileges.

I understand and agree that any significant misstatement in or omissions from this application shall
constitute cause for denial of appointment or cause for summary dismissal from the medical staff with no
right of appeal. All information submitted by me in this application is true to the best of my knowledge and
belief.

I further authorize a photocopy or facsimile of the requests, authorizations, and release to this application
to serve as the original.

________________________________________ _____________________
Signature of Applicant Date

________________________________________
Print Name

Trenton Medical Center, Inc. dba Palms Medical Group will treat this application and any information
secured in connection therewith in confidence and will employ all reasonable safeguards to protect the
applicant’s privacy.

Application of Appointment 6