Medical Professional Application Current Physician Openings Physician Compensation and Benefits Physician Owned and Operated Apply Now About the Community View Our Videos History Menu Current Physician Openings Physician Compensation and Benefits Physician Owned and Operated Apply Now About the Community View Our Videos History Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 5Personal Information This is a secure page LayoutFirst Name *Preferred NameMI *Last Name *LayoutTitle *MDDOAPRNPA-CSocial Security Number *Current Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutContact Number *Email *Have you ever used an alias or other name?YesNoIf so, please list those names:Employment Eligibility Are you legally eligible for employment in the U.S.?YesNo(A physician, upon acceptance, must verify his/her identity and employment eligibility.) Education LayoutMedical School *CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIf you completed medical school outside of the United States, please list the city/province and country.LayoutDate Started *Date Ended * LayoutInternshipInstitutionCityLayoutStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate StartedDate EndedProgram Director LayoutResidency *Institution *CityLayoutState *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate Started *Date Ended *Program Director * LayoutFellowshipInstitutionCityLayoutStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate StartedDate Ended Military ServiceYesNoLayoutBranchDate StartedDate EndedNext >Medical Licensure Please list all states in which you have been licensed, along with license number. If you do not have an active DEA#, CAQH#, NPI# or active state license please enter N/A. LayoutDEA # *ExpiresLayoutCAQH # *UsernamePasswordLayoutNPI # *UsernamePasswordDo you have a Kentucky License?YesnoBoard Certification Please submit proof or board eligibility or certification. Please check the board-certified or board-eligible boxes Primary Board Layout Board-Certified Board-eligible Date to take boardsSubspecialty Board Layout Board-Certified Board-eligible Date to take boardsAdded Qualifications Layout Board-Certified Board-eligible Date to take boardsLayout< PreviousNext >If the answer to any question in the following section is "Yes", please provide a full explanation in the space below. Disciplinary Actions Have any of the following ever been, or are any currently in the process of, being denied, revoked, suspended, reduced, limited, placed on probation, not renewed, or voluntarily or involuntarily relinquished: LayoutLicense to practice any profession in any jurisdiction? *YesNoExplainOther professional registration/license? *YesNoExplainLayoutSpecialty or subspecialty board certification? *YesNoExplainMembership on any hospital medical staff? *YesNoExplainLayoutClinical Privileges *YesNoExplainRights associated with practice on any medical staff? *YesNoExplainLayoutProfessional society membership or fellowship? *YesNoExplainAuthority to prescribe controlled substances? *YesNoExplainLayoutAcademic appointment? *YesNoExplainHMO, PPO, or other health insurance participation? *YesNoExplainLayoutHave you ever been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? *YesNoExplainHave you ever been sanctioned by Medicare, Medicaid, US DHHS, or a professional review organization? *YesNoExplainLayoutHave you ever opted out of Medicare? *YesNoExplainDuring internship, residency, and/or fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? *YesNoExplainLayoutHave you ever left a practice, hospital or other healthcare entity while under investigation for quality of care issues or violations of company policies? *YesNoExplainHave you ever been the subject of reprimand by any administrative agency, medical society, licensing board, hospital or professional organization? *YesNoExplainLayoutHave you ever been examined by a specialty board but failed to pass the exam? *YesNoExplainHave preceptor(s) or assisting physician(s) ever been assigned to any aspect of your practice by a practice or hospital? *YesNoExplainLayoutDo you have any agreements with any current or former employers that in any way restrict future employment activities? (If yes, please be prepared to provide a copy of the agreement) *YesNoExplainClaims/Lawsuits/Professional Liability Insurance LayoutHave you ever been denied professional liability insurance or has your coverage ever been cancelled? *YesNoExplainHave you ever had a report filed against you with the National Practitioner Data Bank? *YesNoExplainLayoutHave any professional liability suits or claims been filed against you? *YesNoExplainHave any professional liability suits or claims been filed against you which are presently pending? *YesNoExplainLayoutHave any judgments or settlements been made against you in professional liability cases? *YesNoExplain (copy)Miscellaneous LayoutAre you able to perform the essential functions involved in delivering safe, efficient, quality care, with or without reasonable accommodations? *YesNoExplainAre you currently using illegal drugs? *YesNoExplainAnswering yes to any of these questions will not automatically exclude an applicant from consideration for employment. Lexington Clinic will consider the nature of the offense and when it occurred when making a hiring decision. < PreviousNext >Professional References LayoutNameTitleAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutContact PhoneFaxEmail LayoutNameTitleAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutContact PhoneFaxEmail LayoutNameTitleAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutContact PhoneFaxEmail< PreviousNext >Acknowledgements/Release by Applicant: Please read all information carefully. All statements made by me on this application, are true and complete to the best of my knowledge and belief. I understand that any information which is falsely given, misstated, or omitted by me on the application or in connection with my consideration for employment may disqualify me from being hired for employment, or, once hired, may result in immediate termination. I hereby authorize Lexington Clinic and its agents to consult with any persons, entities, institutions and/or medical licensing boards who can provide information or documents, privileged or confidential, relating to my professional competence, ethics, employment history, educational background, personal character and professional liability history; and to provide information, both written and oral, regarding the status of any license which I have possessed. I hereby release, acquit and forever discharge Lexington Clinic, its medical staff and its representatives, and any and all other entities, vendors and persons, who may furnish or submit written or oral information in connection with the investigation and processing of this application, from and against any and all liability, claims, causes of action or demands for, or by reason of, any matter which may arise from submission, furnishing, discussion or use of any information described above, either oral or written. I understand that should any offer of employment be tendered, it will be contingent upon successful credentialing, privileging and the passage of a background check and drug testing. LayoutFirst Name *Middle InitialLast Name *Date *Thank you Lexington Clinic is an Equal Opportunity Employer. Single Line Text< PreviousSubmit Application
