KSTAR Physician Assessment Application

Applicant Information
Name Name First Last
Phone Phone - ### - ### ####
Email
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone Work Phone - ### - ### ####
Work Address Work Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female
In what country were you born?
What is your first language?
What is your second language?
Are you currently enrolled in a treatment/monitoring program?

Are you currently enrolled in a treatment/monitoring program? Yes No
Please provide the name of the Treatment program and contact information.
How long have you been drug/alcohol free?
Practice Information
List all states in which you are licensed to practice medicine. (include your license and DEA number)
Has a license to practice medicine requested or possessed by you ever been denied, restrictes, suspended, revoked or voluntarily surrendered in any state? Please explain
Are you currently in practice?

Are you currently in practice? Yes No
I am not currently practicing medicine and I desire to return to practice. Please provide details of current situation.
How long have you been out of practice?
Specialty of current clinical practice
What is the nature of your current practice?

What is the nature of your current practice? Hospital Office Solo practice Group practice University/teaching Military Other Other
How many hours a week?
Do you have admitting privileges?

Do you have admitting privileges? Yes No
Do you have surgical privileges?

Do you have surgical privileges? Yes No
Average number of outpatient surgical procedures per month
Average number of inpatient surgical procedures per month
Average number of deliveries per month
Patient population of your practice, check all that apply

Patient population of your practice, check all that apply 0-5 y/o 6-17 y/o 18-30 y/o 31-54 y/o 55-74 y/o older than 74 y/o
Patient population by patient type

Patient population by patient type Amublatory Inpatient
How long have you been in practice?
Do you know or reasonably suspect there is a review, investigation or disciplinary proceeding under way where you practice?

Do you know or reasonably suspect there is a review, investigation or disciplinary proceeding under way where you practice? Yes No
Name of facility
Please provide details and contact information
Certification

I certify that I agree to participate in the KSTAR program and understand that a formal contract arrangement, to include fees, will be initiated before I am considered to be enrolled in the program.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

KSTAR Physician Assessment Application

Applicant Information

Practice Information

Certification