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History

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United States+1
United Kingdom+44
Afghanistan (‫افغانستان‬‎)+93
Albania (Shqipëri)+355
Algeria (‫الجزائر‬‎)+213
American Samoa+1
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Anguilla+1
Antigua and Barbuda+1
Argentina+54
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Aruba+297
Ascension Island+247
Australia+61
Austria (Österreich)+43
Azerbaijan (Azərbaycan)+994
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Bahrain (‫البحرين‬‎)+973
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Belarus (Беларусь)+375
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Belize+501
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Bermuda+1
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Dominican Republic (República Dominicana)+1
Ecuador+593
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El Salvador+503
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Eswatini+268
Ethiopia+251
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Guinea-Bissau (Guiné Bissau)+245
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Hungary (Magyarország)+36
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Laos (ລາວ)+856
Latvia (Latvija)+371
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Lesotho+266
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Oman (‫عُمان‬‎)+968
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Palestine (‫فلسطين‬‎)+970
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Philippines+63
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Portugal+351
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Romania (România)+40
Russia (Россия)+7
Rwanda+250
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Saint Helena+290
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San Marino+378
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South Sudan (‫جنوب السودان‬‎)+211
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Sudan (‫السودان‬‎)+249
Suriname+597
Svalbard and Jan Mayen+47
Sweden (Sverige)+46
Switzerland (Schweiz)+41
Syria (‫سوريا‬‎)+963
Taiwan (台灣)+886
Tajikistan+992
Tanzania+255
Thailand (ไทย)+66
Timor-Leste+670
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Tokelau+690
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Tunisia (‫تونس‬‎)+216
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Turkmenistan+993
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Tuvalu+688
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United Kingdom+44
United States+1
Uruguay+598
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Vanuatu+678
Vatican City (Città del Vaticano)+39
Venezuela+58
Vietnam (Việt Nam)+84
Wallis and Futuna (Wallis-et-Futuna)+681
Western Sahara (‫الصحراء الغربية‬‎)+212
Yemen (‫اليمن‬‎)+967
Zambia+260
Zimbabwe+263
Åland Islands+358

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If so, please list those names:

Employment Eligibility

Are you legally eligible for employment in the U.S.?

(A physician, upon acceptance, must verify his/her identity and employment eligibility.)

Education

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State

If you completed medical school outside of the United States, please list the city/province and country.

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Date Started *

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Internship

Institution

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State

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Program Director

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Residency *

Institution *

City

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State *

Date Started *

Date Ended *

Program Director *

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Fellowship

Institution

City

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State

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Date Ended

Military Service

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Branch

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Date Ended

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.

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DEA # *

Expires

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CAQH # *

Username

Password

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NPI # *

Username

Password

Do you have a Kentucky License?

Board Certification

Please submit proof or board eligibility or certification. Please check the board-certified or board-eligible boxes

Primary Board

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Board-Certified

Board-eligible

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Subspecialty Board

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Board-Certified

Board-eligible

Date to take boards

Added Qualifications

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Board-Certified

Board-eligible

Date to take boards

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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:

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License to practice any profession in any jurisdiction? *

Explain

Other professional registration/license? *

Explain

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Specialty or subspecialty board certification? *

Explain

Membership on any hospital medical staff? *

Explain

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Clinical Privileges *

Explain

Rights associated with practice on any medical staff? *

Explain

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Professional society membership or fellowship? *

Explain

Authority to prescribe controlled substances? *

Explain

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Academic appointment? *

Explain

HMO, PPO, or other health insurance participation? *

Explain

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Have you ever been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? *

Explain

Have you ever been sanctioned by Medicare, Medicaid, US DHHS, or a professional review organization? *

Explain

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Have you ever opted out of Medicare? *

Explain

During internship, residency, and/or fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? *

Explain

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Have you ever left a practice, hospital or other healthcare entity while under investigation for quality of care issues or violations of company policies? *

Explain

Have you ever been the subject of reprimand by any administrative agency, medical society, licensing board, hospital or professional organization? *

Explain

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Have you ever been examined by a specialty board but failed to pass the exam? *

Explain

Have preceptor(s) or assisting physician(s) ever been assigned to any aspect of your practice by a practice or hospital? *

Explain

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Do 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) *

Explain

Claims/Lawsuits/Professional Liability Insurance

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Have you ever been denied professional liability insurance or has your coverage ever been cancelled? *

Explain

Have you ever had a report filed against you with the National Practitioner Data Bank? *

Explain

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Have any professional liability suits or claims been filed against you? *

Explain

Have any professional liability suits or claims been filed against you which are presently pending? *

Explain

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Have any judgments or settlements been made against you in professional liability cases? *

Explain (copy)

Miscellaneous

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Are you able to perform the essential functions involved in delivering safe, efficient, quality care, with or without reasonable accommodations? *

Explain

Are you currently using illegal drugs? *

Explain

Answering 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.

Professional References

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Name

Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Contact Phone

United States+1
United Kingdom+44
Afghanistan (‫افغانستان‬‎)+93
Albania (Shqipëri)+355
Algeria (‫الجزائر‬‎)+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua and Barbuda+1
Argentina+54
Armenia (Հայաստան)+374
Aruba+297
Ascension Island+247
Australia+61
Austria (Österreich)+43
Azerbaijan (Azərbaycan)+994
Bahamas+1
Bahrain (‫البحرين‬‎)+973
Bangladesh (বাংলাদেশ)+880
Barbados+1
Belarus (Беларусь)+375
Belgium (België)+32
Belize+501
Benin (Bénin)+229
Bermuda+1
Bhutan (འབྲུག)+975
Bolivia+591
Bosnia and Herzegovina (Босна и Херцеговина)+387
Botswana+267
Brazil (Brasil)+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria (България)+359
Burkina Faso+226
Burundi (Uburundi)+257
Cambodia (កម្ពុជា)+855
Cameroon (Cameroun)+237
Canada+1
Cape Verde (Kabu Verdi)+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic (République centrafricaine)+236
Chad (Tchad)+235
Chile+56
China (中国)+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros (‫جزر القمر‬‎)+269
Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
Congo (Republic) (Congo-Brazzaville)+242
Cook Islands+682
Costa Rica+506
Côte d’Ivoire+225
Croatia (Hrvatska)+385
Cuba+53
Curaçao+599
Cyprus (Κύπρος)+357
Czech Republic (Česká republika)+420
Denmark (Danmark)+45
Djibouti+253
Dominica+1
Dominican Republic (República Dominicana)+1
Ecuador+593
Egypt (‫مصر‬‎)+20
El Salvador+503
Equatorial Guinea (Guinea Ecuatorial)+240
Eritrea+291
Estonia (Eesti)+372
Eswatini+268
Ethiopia+251
Falkland Islands (Islas Malvinas)+500
Faroe Islands (Føroyar)+298
Fiji+679
Finland (Suomi)+358
France+33
French Guiana (Guyane française)+594
French Polynesia (Polynésie française)+689
Gabon+241
Gambia+220
Georgia (საქართველო)+995
Germany (Deutschland)+49
Ghana (Gaana)+233
Gibraltar+350
Greece (Ελλάδα)+30
Greenland (Kalaallit Nunaat)+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea (Guinée)+224
Guinea-Bissau (Guiné Bissau)+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong (香港)+852
Hungary (Magyarország)+36
Iceland (Ísland)+354
India (भारत)+91
Indonesia+62
Iran (‫ایران‬‎)+98
Iraq (‫العراق‬‎)+964
Ireland+353
Isle of Man+44
Israel (‫ישראל‬‎)+972
Italy (Italia)+39
Jamaica+1
Japan (日本)+81
Jersey+44
Jordan (‫الأردن‬‎)+962
Kazakhstan (Казахстан)+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait (‫الكويت‬‎)+965
Kyrgyzstan (Кыргызстан)+996
Laos (ລາວ)+856
Latvia (Latvija)+371
Lebanon (‫لبنان‬‎)+961
Lesotho+266
Liberia+231
Libya (‫ليبيا‬‎)+218
Liechtenstein+423
Lithuania (Lietuva)+370
Luxembourg+352
Macau (澳門)+853
North Macedonia (Македонија)+389
Madagascar (Madagasikara)+261
Malawi+265
Malaysia+60
Maldives+960
Mali+223
Malta+356
Marshall Islands+692
Martinique+596
Mauritania (‫موريتانيا‬‎)+222
Mauritius (Moris)+230
Mayotte+262
Mexico (México)+52
Micronesia+691
Moldova (Republica Moldova)+373
Monaco+377
Mongolia (Монгол)+976
Montenegro (Crna Gora)+382
Montserrat+1
Morocco (‫المغرب‬‎)+212
Mozambique (Moçambique)+258
Myanmar (Burma) (မြန်မာ)+95
Namibia (Namibië)+264
Nauru+674
Nepal (नेपाल)+977
Netherlands (Nederland)+31
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New Zealand+64
Nicaragua+505
Niger (Nijar)+227
Nigeria+234
Niue+683
Norfolk Island+672
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Northern Mariana Islands+1
Norway (Norge)+47
Oman (‫عُمان‬‎)+968
Pakistan (‫پاکستان‬‎)+92
Palau+680
Palestine (‫فلسطين‬‎)+970
Panama (Panamá)+507
Papua New Guinea+675
Paraguay+595
Peru (Perú)+51
Philippines+63
Poland (Polska)+48
Portugal+351
Puerto Rico+1
Qatar (‫قطر‬‎)+974
Réunion (La Réunion)+262
Romania (România)+40
Russia (Россия)+7
Rwanda+250
Saint Barthélemy+590
Saint Helena+290
Saint Kitts and Nevis+1
Saint Lucia+1
Saint Martin (Saint-Martin (partie française))+590
Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
Saint Vincent and the Grenadines+1
Samoa+685
San Marino+378
São Tomé and Príncipe (São Tomé e Príncipe)+239
Saudi Arabia (‫المملكة العربية السعودية‬‎)+966
Senegal (Sénégal)+221
Serbia (Србија)+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia (Slovensko)+421
Slovenia (Slovenija)+386
Solomon Islands+677
Somalia (Soomaaliya)+252
South Africa+27
South Korea (대한민국)+82
South Sudan (‫جنوب السودان‬‎)+211
Spain (España)+34
Sri Lanka (ශ්‍රී ලංකාව)+94
Sudan (‫السودان‬‎)+249
Suriname+597
Svalbard and Jan Mayen+47
Sweden (Sverige)+46
Switzerland (Schweiz)+41
Syria (‫سوريا‬‎)+963
Taiwan (台灣)+886
Tajikistan+992
Tanzania+255
Thailand (ไทย)+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad and Tobago+1
Tunisia (‫تونس‬‎)+216
Turkey (Türkiye)+90
Turkmenistan+993
Turks and Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine (Україна)+380
United Arab Emirates (‫الإمارات العربية المتحدة‬‎)+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan (Oʻzbekiston)+998
Vanuatu+678
Vatican City (Città del Vaticano)+39
Venezuela+58
Vietnam (Việt Nam)+84
Wallis and Futuna (Wallis-et-Futuna)+681
Western Sahara (‫الصحراء الغربية‬‎)+212
Yemen (‫اليمن‬‎)+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Fax

United States+1
United Kingdom+44
Afghanistan (‫افغانستان‬‎)+93
Albania (Shqipëri)+355
Algeria (‫الجزائر‬‎)+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua and Barbuda+1
Argentina+54
Armenia (Հայաստան)+374
Aruba+297
Ascension Island+247
Australia+61
Austria (Österreich)+43
Azerbaijan (Azərbaycan)+994
Bahamas+1
Bahrain (‫البحرين‬‎)+973
Bangladesh (বাংলাদেশ)+880
Barbados+1
Belarus (Беларусь)+375
Belgium (België)+32
Belize+501
Benin (Bénin)+229
Bermuda+1
Bhutan (འབྲུག)+975
Bolivia+591
Bosnia and Herzegovina (Босна и Херцеговина)+387
Botswana+267
Brazil (Brasil)+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria (България)+359
Burkina Faso+226
Burundi (Uburundi)+257
Cambodia (កម្ពុជា)+855
Cameroon (Cameroun)+237
Canada+1
Cape Verde (Kabu Verdi)+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic (République centrafricaine)+236
Chad (Tchad)+235
Chile+56
China (中国)+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros (‫جزر القمر‬‎)+269
Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
Congo (Republic) (Congo-Brazzaville)+242
Cook Islands+682
Costa Rica+506
Côte d’Ivoire+225
Croatia (Hrvatska)+385
Cuba+53
Curaçao+599
Cyprus (Κύπρος)+357
Czech Republic (Česká republika)+420
Denmark (Danmark)+45
Djibouti+253
Dominica+1
Dominican Republic (República Dominicana)+1
Ecuador+593
Egypt (‫مصر‬‎)+20
El Salvador+503
Equatorial Guinea (Guinea Ecuatorial)+240
Eritrea+291
Estonia (Eesti)+372
Eswatini+268
Ethiopia+251
Falkland Islands (Islas Malvinas)+500
Faroe Islands (Føroyar)+298
Fiji+679
Finland (Suomi)+358
France+33
French Guiana (Guyane française)+594
French Polynesia (Polynésie française)+689
Gabon+241
Gambia+220
Georgia (საქართველო)+995
Germany (Deutschland)+49
Ghana (Gaana)+233
Gibraltar+350
Greece (Ελλάδα)+30
Greenland (Kalaallit Nunaat)+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea (Guinée)+224
Guinea-Bissau (Guiné Bissau)+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong (香港)+852
Hungary (Magyarország)+36
Iceland (Ísland)+354
India (भारत)+91
Indonesia+62
Iran (‫ایران‬‎)+98
Iraq (‫العراق‬‎)+964
Ireland+353
Isle of Man+44
Israel (‫ישראל‬‎)+972
Italy (Italia)+39
Jamaica+1
Japan (日本)+81
Jersey+44
Jordan (‫الأردن‬‎)+962
Kazakhstan (Казахстан)+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait (‫الكويت‬‎)+965
Kyrgyzstan (Кыргызстан)+996
Laos (ລາວ)+856
Latvia (Latvija)+371
Lebanon (‫لبنان‬‎)+961
Lesotho+266
Liberia+231
Libya (‫ليبيا‬‎)+218
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British Indian Ocean Territory+246
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Nigeria+234
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Northern Mariana Islands+1
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Oman (‫عُمان‬‎)+968
Pakistan (‫پاکستان‬‎)+92
Palau+680
Palestine (‫فلسطين‬‎)+970
Panama (Panamá)+507
Papua New Guinea+675
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Philippines+63
Poland (Polska)+48
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Saudi Arabia (‫المملكة العربية السعودية‬‎)+966
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Serbia (Србија)+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia (Slovensko)+421
Slovenia (Slovenija)+386
Solomon Islands+677
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South Africa+27
South Korea (대한민국)+82
South Sudan (‫جنوب السودان‬‎)+211
Spain (España)+34
Sri Lanka (ශ්‍රී ලංකාව)+94
Sudan (‫السودان‬‎)+249
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Taiwan (台灣)+886
Tajikistan+992
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Tokelau+690
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Vietnam (Việt Nam)+84
Wallis and Futuna (Wallis-et-Futuna)+681
Western Sahara (‫الصحراء الغربية‬‎)+212
Yemen (‫اليمن‬‎)+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Fax

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United Kingdom+44
Afghanistan (‫افغانستان‬‎)+93
Albania (Shqipëri)+355
Algeria (‫الجزائر‬‎)+213
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Angola+244
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Antigua and Barbuda+1
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Armenia (Հայաստան)+374
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Austria (Österreich)+43
Azerbaijan (Azərbaycan)+994
Bahamas+1
Bahrain (‫البحرين‬‎)+973
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Belarus (Беларусь)+375
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Belize+501
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Bermuda+1
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Botswana+267
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British Indian Ocean Territory+246
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Cape Verde (Kabu Verdi)+238
Caribbean Netherlands+599
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Chile+56
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Congo (Republic) (Congo-Brazzaville)+242
Cook Islands+682
Costa Rica+506
Côte d’Ivoire+225
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Cuba+53
Curaçao+599
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Czech Republic (Česká republika)+420
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Jordan (‫الأردن‬‎)+962
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Kyrgyzstan (Кыргызстан)+996
Laos (ລາວ)+856
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Lebanon (‫لبنان‬‎)+961
Lesotho+266
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Luxembourg+352
Macau (澳門)+853
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Marshall Islands+692
Martinique+596
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Turkey (Türkiye)+90
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Uzbekistan (Oʻzbekiston)+998
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Vatican City (Città del Vaticano)+39
Venezuela+58
Vietnam (Việt Nam)+84
Wallis and Futuna (Wallis-et-Futuna)+681
Western Sahara (‫الصحراء الغربية‬‎)+212
Yemen (‫اليمن‬‎)+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Layout

Name

Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Contact Phone

United States+1
United Kingdom+44
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Albania (Shqipëri)+355
Algeria (‫الجزائر‬‎)+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua and Barbuda+1
Argentina+54
Armenia (Հայաստան)+374
Aruba+297
Ascension Island+247
Australia+61
Austria (Österreich)+43
Azerbaijan (Azərbaycan)+994
Bahamas+1
Bahrain (‫البحرين‬‎)+973
Bangladesh (বাংলাদেশ)+880
Barbados+1
Belarus (Беларусь)+375
Belgium (België)+32
Belize+501
Benin (Bénin)+229
Bermuda+1
Bhutan (འབྲུག)+975
Bolivia+591
Bosnia and Herzegovina (Босна и Херцеговина)+387
Botswana+267
Brazil (Brasil)+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria (България)+359
Burkina Faso+226
Burundi (Uburundi)+257
Cambodia (កម្ពុជា)+855
Cameroon (Cameroun)+237
Canada+1
Cape Verde (Kabu Verdi)+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic (République centrafricaine)+236
Chad (Tchad)+235
Chile+56
China (中国)+86
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Cocos (Keeling) Islands+61
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Comoros (‫جزر القمر‬‎)+269
Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
Congo (Republic) (Congo-Brazzaville)+242
Cook Islands+682
Costa Rica+506
Côte d’Ivoire+225
Croatia (Hrvatska)+385
Cuba+53
Curaçao+599
Cyprus (Κύπρος)+357
Czech Republic (Česká republika)+420
Denmark (Danmark)+45
Djibouti+253
Dominica+1
Dominican Republic (República Dominicana)+1
Ecuador+593
Egypt (‫مصر‬‎)+20
El Salvador+503
Equatorial Guinea (Guinea Ecuatorial)+240
Eritrea+291
Estonia (Eesti)+372
Eswatini+268
Ethiopia+251
Falkland Islands (Islas Malvinas)+500
Faroe Islands (Føroyar)+298
Fiji+679
Finland (Suomi)+358
France+33
French Guiana (Guyane française)+594
French Polynesia (Polynésie française)+689
Gabon+241
Gambia+220
Georgia (საქართველო)+995
Germany (Deutschland)+49
Ghana (Gaana)+233
Gibraltar+350
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Greenland (Kalaallit Nunaat)+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea (Guinée)+224
Guinea-Bissau (Guiné Bissau)+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong (香港)+852
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India (भारत)+91
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Iran (‫ایران‬‎)+98
Iraq (‫العراق‬‎)+964
Ireland+353
Isle of Man+44
Israel (‫ישראל‬‎)+972
Italy (Italia)+39
Jamaica+1
Japan (日本)+81
Jersey+44
Jordan (‫الأردن‬‎)+962
Kazakhstan (Казахстан)+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait (‫الكويت‬‎)+965
Kyrgyzstan (Кыргызстан)+996
Laos (ລາວ)+856
Latvia (Latvija)+371
Lebanon (‫لبنان‬‎)+961
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Fax

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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.

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Lexington Clinic is an Equal Opportunity Employer.

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Interested candidates please contact:

Alexis Sturgill

Tammy Spivey, PHR, SHRM-CP

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