This 15-page practitioner volunteer/employment application document requests extensive personal and professional information from applicants. Section I requests personal information. Section II requests information about primary office practice and cross-coverage arrangements. Section III requests education and training details. Sections IV and V request hospital affiliation and work history. Following sections request additional details including licensure, board certification, references, liability insurance, claims history, health status, and questions pertaining to professional practice. The application aims to gather a comprehensive profile of a practitioner's qualifications, experience, and background.
1. The document provides instructions for applicants taking the Foreign Service Officer Examinations administered by the Department of Foreign Affairs of the Philippines.
2. It outlines the application process and requirements, including submitting a completed application with attachments by the specified deadlines.
3. Applicants must agree to accept all BFSE decisions, take an oath that all information provided is true, and understand false statements could result in prosecution.
1) The document is an application for the 2016 Foreign Service Officer Examinations administered by the Department of Foreign Affairs of the Philippines.
2) It provides instructions for applicants to fully and accurately complete the application form and attach all necessary documents. Incomplete applications will not be accepted.
3) The application asks for personal details, education history, employment history, language proficiency, and other information from applicants, who must sign an oath that all information provided is true and correct.
The document announces the 2016 Foreign Service Officer (FSO) examination in the Philippines. It details the application process and requirements to sit for the 5-part examination, which includes a qualifying test, preliminary interview, written test, psychological test, and oral test. Applicants must pass all parts sequentially and meet the requirements, which include Philippine citizenship, maximum age of 35, a 4-year bachelor's degree, and 2 years of work or further study experience. The duties of an FSO include gathering information, drafting correspondence, assisting in international conferences, and more.
Nu Rn International Application Ces Vermontjeffy1988
This document provides instructions for international nurses applying for RN licensure by examination or endorsement in Vermont. Applicants must complete a credentials evaluation with CGFNS or IERF, then submit Vermont's application with the $150 fee, a photo, copies of their passport, current nursing license, and NCLEX fail letters if applicable. The application collects contact, education, and licensing information and must be fully completed for review. Questions should first check the website and applicants should review all instructions carefully before submitting their application.
This document is a registration form for a recruitment test for Sub Station Operator positions I and II with the National Transmission & Despatch Company Ltd. It requests personal information such as name, CNIC number, date of birth, contact details, education history, employment history, and photographs. It specifies eligibility criteria like age limits, educational qualifications, experience requirements, and preferred test city. It also contains sections for information on government service, disabilities, and being a child or widow of an NTDCL employee. The form must be submitted along with supporting documents by November 18, 2014 to the National Testing Service.
This document is a registration form for a recruitment test administered by the National Transmission and Despatch Company Ltd. (NTDCL). The form collects personal information such as name, address, contact details, education history, and employment experience. It also asks the applicant to select their desired post, province, and test city. Documentation requirements include photographs, CNIC, academic and experience certificates. The deadline to submit the completed form to the National Testing Service is November 18, 2014.
The document provides information about the results of the March 22, 2015 Penology Officer Examination. It states that examination results can be viewed on the Civil Service Commission website starting May 18, 2015. For those who passed, Certificates of Eligibility can be claimed from the relevant CSC Regional Office starting June 3, 2015 by presenting a valid ID and photos. The advisory also lists the ID documents accepted and provides contact information for inquiries about examination results.
This document is an application form for a civil service examination. It requests information such as the applicant's name, contact details, education history, and employment history. It provides instructions for applicants regarding the examination process and requirements. Applicants must be citizens of good moral character and not have any convictions. They must bring their application form, valid ID, and examination supplies on the scheduled examination day.
1. The document provides instructions for applicants taking the Foreign Service Officer Examinations administered by the Department of Foreign Affairs of the Philippines.
2. It outlines the application process and requirements, including submitting a completed application with attachments by the specified deadlines.
3. Applicants must agree to accept all BFSE decisions, take an oath that all information provided is true, and understand false statements could result in prosecution.
1) The document is an application for the 2016 Foreign Service Officer Examinations administered by the Department of Foreign Affairs of the Philippines.
2) It provides instructions for applicants to fully and accurately complete the application form and attach all necessary documents. Incomplete applications will not be accepted.
3) The application asks for personal details, education history, employment history, language proficiency, and other information from applicants, who must sign an oath that all information provided is true and correct.
The document announces the 2016 Foreign Service Officer (FSO) examination in the Philippines. It details the application process and requirements to sit for the 5-part examination, which includes a qualifying test, preliminary interview, written test, psychological test, and oral test. Applicants must pass all parts sequentially and meet the requirements, which include Philippine citizenship, maximum age of 35, a 4-year bachelor's degree, and 2 years of work or further study experience. The duties of an FSO include gathering information, drafting correspondence, assisting in international conferences, and more.
Nu Rn International Application Ces Vermontjeffy1988
This document provides instructions for international nurses applying for RN licensure by examination or endorsement in Vermont. Applicants must complete a credentials evaluation with CGFNS or IERF, then submit Vermont's application with the $150 fee, a photo, copies of their passport, current nursing license, and NCLEX fail letters if applicable. The application collects contact, education, and licensing information and must be fully completed for review. Questions should first check the website and applicants should review all instructions carefully before submitting their application.
This document is a registration form for a recruitment test for Sub Station Operator positions I and II with the National Transmission & Despatch Company Ltd. It requests personal information such as name, CNIC number, date of birth, contact details, education history, employment history, and photographs. It specifies eligibility criteria like age limits, educational qualifications, experience requirements, and preferred test city. It also contains sections for information on government service, disabilities, and being a child or widow of an NTDCL employee. The form must be submitted along with supporting documents by November 18, 2014 to the National Testing Service.
This document is a registration form for a recruitment test administered by the National Transmission and Despatch Company Ltd. (NTDCL). The form collects personal information such as name, address, contact details, education history, and employment experience. It also asks the applicant to select their desired post, province, and test city. Documentation requirements include photographs, CNIC, academic and experience certificates. The deadline to submit the completed form to the National Testing Service is November 18, 2014.
The document provides information about the results of the March 22, 2015 Penology Officer Examination. It states that examination results can be viewed on the Civil Service Commission website starting May 18, 2015. For those who passed, Certificates of Eligibility can be claimed from the relevant CSC Regional Office starting June 3, 2015 by presenting a valid ID and photos. The advisory also lists the ID documents accepted and provides contact information for inquiries about examination results.
This document is an application form for a civil service examination. It requests information such as the applicant's name, contact details, education history, and employment history. It provides instructions for applicants regarding the examination process and requirements. Applicants must be citizens of good moral character and not have any convictions. They must bring their application form, valid ID, and examination supplies on the scheduled examination day.
This document is an application form for a civil service examination in the Philippines. It requests information such as the applicant's personal details, education history, and employment records. It also provides instructions on the application process and requirements, including submitting identification documents and paying an examination fee. The form notes that applicants must meet eligibility criteria such as citizenship, age, and good moral character. It warns that cheating will not be tolerated and violators will face administrative and criminal penalties under Philippine law.
The document is a registration form for a recruitment test for the position of Laboratory Assistant BPS-14 held by the National Transmission & Despatch Company Ltd. It requests information such as personal details, qualifications, experience, and preferred test location. Eligibility requirements include being aged 18-30 years old and possessing a matric degree with a 3-year diploma in electrical/electronics from a recognized technical institute with a minimum grade B. The deadline to submit the completed registration form to the National Testing Service is November 18th, 2014.
The document provides guidelines for filling out Form-8, which is used to apply for corrections to one's entry on the electoral roll. It outlines who can file Form-8, when and where it can be filed, and how to fill out each section to correctly provide details of the requested correction along with necessary supporting documents. Applicants are instructed to clearly indicate in Part IV of the form which specific details listed need to be corrected based on the updated information provided.
This document is an application form for admission to post-graduate programs at the Indian Institute of Technology Kanpur. It requests personal information such as name, date of birth, contact details, academic history including degrees earned and marks/grades, work experience, research papers published, and preferred areas of study. It includes instructions for filling out the form and codes for different application items. Completed forms must be submitted by specific deadlines depending on the semester of intended admission.
This document is a lengthy application form for a nursing position. It requests personal details, contact information, addresses, qualifications, employment history, references, health declarations, and notes. It informs the applicant that incomplete forms will be returned, and that the agency will need to process personal data for safety and suitability assessments. The applicant must sign declaring the information is accurate and agreeing to the data processing before returning the completed form.
Prohibited conduct-questionnaire-signed to Judge EliasDouglas GARDINER
This document provides forms for complainants and respondents related to discrimination complaints under the Equality Act 2010 in the UK. The complainant's questions form guides them to provide details about their protected characteristics, treatment experienced, and questions for the respondent. The respondent's answers form allows the respondent to respond to the complainant's description of events, state whether the treatment was unlawful, and answer their questions. Instructions are provided on how to complete the forms and serve them to the other party.
This document appears to be a job application for a position with the University of Wisconsin-Milwaukee Police Department. The multi-page application requests personal information, education history, employment history, military service details if applicable, references, and answers to supplemental questions. It also includes notices that any false statements made in the application may result in denial of employment or termination, and authorizes the university to conduct a criminal background check.
The document outlines the requirements for applying to work as a live-in caregiver in Canada. It lists credentials needed including a 6-month caregiver certificate and transcript of records, certificates for elderly, child and disability care experience, a bachelor's degree transcript or 72 college units, an NC2 certificate, a reference letter from a current employer in caregiving, a passport, police clearances, and authenticated documents. Additional documents would need to be provided to a Canadian consulate after securing a job offer and employer sponsorship in Canada, including application forms, a processing fee, and a signed employment contract.
Lok Sabha Elections 2014 start from the 7th of April. Voters need to be perfectly ready with their up-to-date Voter ID Cards. This Voter Form No. 8 would help you rectify the errors in your Voter Details.
This document is an application form for a civil service examination. It requests information such as the applicant's personal details, educational background, employment history, and a declaration acknowledging the rules of the examination. The form must be filled out in person by the applicant and submitted along with a valid ID, application fee, and photos meeting specifications. Applicants may be disqualified for certain offenses or if found cheating on examinations.
http://blog.uclaimgprogram.org
Postgraduate Training Authorization Letter or California Letter Application Guideline for International Medical Graduates
This document is a bio-data form for applicants applying to the Federal Public Service Commission of Pakistan. It requests personal information such as name, CNIC number, academic qualifications from matriculation onwards, courses and training completed, research experience, employment history, and a checklist of required supporting documents. The applicant must declare that they are not in possession of any other domicile certificate other than the one submitted and that any false information provided could result in termination of employment.
This document is a bio-data form for applicants applying to the Federal Public Service Commission of Pakistan. It requests personal information such as name, CNIC number, academic qualifications from matriculation onwards, courses and training completed, research experience, employment history, and a checklist of required supporting documents. The applicant must declare that they are not in possession of any other domicile certificate other than the one submitted and that any false information provided could result in termination of employment.
The document provides information about Optional Practical Training (OPT) for F-1 visa students at UTEP. It defines OPT as temporary employment directly related to a student's major that is authorized for up to 12 months after degree completion. To be eligible for OPT, students must be in valid F-1 status, be currently enrolled full-time at UTEP, and have been enrolled full-time for one academic year. The document provides timelines and procedures for applying for OPT, including application deadlines and processing times. It outlines OPT eligibility requirements, application steps through UTEP's OIP office and USCIS, conditions of OPT employment, and consequences of unemployment periods over 90 days.
The workshop covered the process for applying for Optional Practical Training (OPT) following completion of a degree program. It discussed OPT eligibility requirements, the application timeline and procedures, how to fill out the application forms and supporting documents, and important reporting obligations during the OPT period. Students were provided guidance on choosing an OPT start date, submitting their application, tracking its status, and notifying the university international student office of any changes.
University of gloucestershire Into university-of-gloucestershire-application-...Abhishek Bajaj
This document is an application form for a student applying to study at the University of Gloucestershire through INTO. It requests personal details, contact information, education history, English language proficiency, course selection, accommodation preferences, and declarations. The applicant must return the completed form at least one month before their intended start date.
Alexander Maynard has applied for the position of Biomedical Scientist at Spire Healthcare Ltd. He is currently studying for a BSc in Biomedical Science at Sheffield Hallam University, where he is in his final year. His previous work experience includes a temporary role answering calls for the National Shielding Helpline during the COVID-19 pandemic. He believes he is a suitable candidate as he is eager to begin his career in healthcare and gain experience in a role like the one being advertised. His academic referee is listed as his academic tutor Paula Simpkin from Sheffield Hallam University.
(1) The document is an application form for joining the Bangladesh Air Force as an officer cadet submitted by Mowrin Ahasan. It contains personal details like name, age, address, educational qualifications, family details, and a declaration signed by the candidate.
(2) The form provides information to assess the candidate's eligibility, including their date of birth, religion, identity marks, emergency contacts, educational records, hobbies, and health details. It also asks if the candidate or their family members have had any prior military service.
(3) By filling out and signing the form, Mowrin Ahasan attests that all information provided is accurate and understands disciplinary action could be taken if
Professional Liability Insurance Application for Allied and Miscellaneous Ser...evaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for allied and other miscellanous services.
PL Applications for Healthcare Professionals, Nursesevaj171
Professional Liability Applications available for Healthcare Professionals, Nurses, Adult Day Care, Alcohol & Drug Rehab, Clinics, Home Health Risks, & Pharmacies, just to name a few!
healthcare professional liability insurance Application for Allied and other ...evaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for allied and other miscellanous services.
Professional Liability Insurance application for Adult day careevaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for Adult Day Care.
This document is an application form for a civil service examination in the Philippines. It requests information such as the applicant's personal details, education history, and employment records. It also provides instructions on the application process and requirements, including submitting identification documents and paying an examination fee. The form notes that applicants must meet eligibility criteria such as citizenship, age, and good moral character. It warns that cheating will not be tolerated and violators will face administrative and criminal penalties under Philippine law.
The document is a registration form for a recruitment test for the position of Laboratory Assistant BPS-14 held by the National Transmission & Despatch Company Ltd. It requests information such as personal details, qualifications, experience, and preferred test location. Eligibility requirements include being aged 18-30 years old and possessing a matric degree with a 3-year diploma in electrical/electronics from a recognized technical institute with a minimum grade B. The deadline to submit the completed registration form to the National Testing Service is November 18th, 2014.
The document provides guidelines for filling out Form-8, which is used to apply for corrections to one's entry on the electoral roll. It outlines who can file Form-8, when and where it can be filed, and how to fill out each section to correctly provide details of the requested correction along with necessary supporting documents. Applicants are instructed to clearly indicate in Part IV of the form which specific details listed need to be corrected based on the updated information provided.
This document is an application form for admission to post-graduate programs at the Indian Institute of Technology Kanpur. It requests personal information such as name, date of birth, contact details, academic history including degrees earned and marks/grades, work experience, research papers published, and preferred areas of study. It includes instructions for filling out the form and codes for different application items. Completed forms must be submitted by specific deadlines depending on the semester of intended admission.
This document is a lengthy application form for a nursing position. It requests personal details, contact information, addresses, qualifications, employment history, references, health declarations, and notes. It informs the applicant that incomplete forms will be returned, and that the agency will need to process personal data for safety and suitability assessments. The applicant must sign declaring the information is accurate and agreeing to the data processing before returning the completed form.
Prohibited conduct-questionnaire-signed to Judge EliasDouglas GARDINER
This document provides forms for complainants and respondents related to discrimination complaints under the Equality Act 2010 in the UK. The complainant's questions form guides them to provide details about their protected characteristics, treatment experienced, and questions for the respondent. The respondent's answers form allows the respondent to respond to the complainant's description of events, state whether the treatment was unlawful, and answer their questions. Instructions are provided on how to complete the forms and serve them to the other party.
This document appears to be a job application for a position with the University of Wisconsin-Milwaukee Police Department. The multi-page application requests personal information, education history, employment history, military service details if applicable, references, and answers to supplemental questions. It also includes notices that any false statements made in the application may result in denial of employment or termination, and authorizes the university to conduct a criminal background check.
The document outlines the requirements for applying to work as a live-in caregiver in Canada. It lists credentials needed including a 6-month caregiver certificate and transcript of records, certificates for elderly, child and disability care experience, a bachelor's degree transcript or 72 college units, an NC2 certificate, a reference letter from a current employer in caregiving, a passport, police clearances, and authenticated documents. Additional documents would need to be provided to a Canadian consulate after securing a job offer and employer sponsorship in Canada, including application forms, a processing fee, and a signed employment contract.
Lok Sabha Elections 2014 start from the 7th of April. Voters need to be perfectly ready with their up-to-date Voter ID Cards. This Voter Form No. 8 would help you rectify the errors in your Voter Details.
This document is an application form for a civil service examination. It requests information such as the applicant's personal details, educational background, employment history, and a declaration acknowledging the rules of the examination. The form must be filled out in person by the applicant and submitted along with a valid ID, application fee, and photos meeting specifications. Applicants may be disqualified for certain offenses or if found cheating on examinations.
http://blog.uclaimgprogram.org
Postgraduate Training Authorization Letter or California Letter Application Guideline for International Medical Graduates
This document is a bio-data form for applicants applying to the Federal Public Service Commission of Pakistan. It requests personal information such as name, CNIC number, academic qualifications from matriculation onwards, courses and training completed, research experience, employment history, and a checklist of required supporting documents. The applicant must declare that they are not in possession of any other domicile certificate other than the one submitted and that any false information provided could result in termination of employment.
This document is a bio-data form for applicants applying to the Federal Public Service Commission of Pakistan. It requests personal information such as name, CNIC number, academic qualifications from matriculation onwards, courses and training completed, research experience, employment history, and a checklist of required supporting documents. The applicant must declare that they are not in possession of any other domicile certificate other than the one submitted and that any false information provided could result in termination of employment.
The document provides information about Optional Practical Training (OPT) for F-1 visa students at UTEP. It defines OPT as temporary employment directly related to a student's major that is authorized for up to 12 months after degree completion. To be eligible for OPT, students must be in valid F-1 status, be currently enrolled full-time at UTEP, and have been enrolled full-time for one academic year. The document provides timelines and procedures for applying for OPT, including application deadlines and processing times. It outlines OPT eligibility requirements, application steps through UTEP's OIP office and USCIS, conditions of OPT employment, and consequences of unemployment periods over 90 days.
The workshop covered the process for applying for Optional Practical Training (OPT) following completion of a degree program. It discussed OPT eligibility requirements, the application timeline and procedures, how to fill out the application forms and supporting documents, and important reporting obligations during the OPT period. Students were provided guidance on choosing an OPT start date, submitting their application, tracking its status, and notifying the university international student office of any changes.
University of gloucestershire Into university-of-gloucestershire-application-...Abhishek Bajaj
This document is an application form for a student applying to study at the University of Gloucestershire through INTO. It requests personal details, contact information, education history, English language proficiency, course selection, accommodation preferences, and declarations. The applicant must return the completed form at least one month before their intended start date.
Alexander Maynard has applied for the position of Biomedical Scientist at Spire Healthcare Ltd. He is currently studying for a BSc in Biomedical Science at Sheffield Hallam University, where he is in his final year. His previous work experience includes a temporary role answering calls for the National Shielding Helpline during the COVID-19 pandemic. He believes he is a suitable candidate as he is eager to begin his career in healthcare and gain experience in a role like the one being advertised. His academic referee is listed as his academic tutor Paula Simpkin from Sheffield Hallam University.
(1) The document is an application form for joining the Bangladesh Air Force as an officer cadet submitted by Mowrin Ahasan. It contains personal details like name, age, address, educational qualifications, family details, and a declaration signed by the candidate.
(2) The form provides information to assess the candidate's eligibility, including their date of birth, religion, identity marks, emergency contacts, educational records, hobbies, and health details. It also asks if the candidate or their family members have had any prior military service.
(3) By filling out and signing the form, Mowrin Ahasan attests that all information provided is accurate and understands disciplinary action could be taken if
Professional Liability Insurance Application for Allied and Miscellaneous Ser...evaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for allied and other miscellanous services.
PL Applications for Healthcare Professionals, Nursesevaj171
Professional Liability Applications available for Healthcare Professionals, Nurses, Adult Day Care, Alcohol & Drug Rehab, Clinics, Home Health Risks, & Pharmacies, just to name a few!
healthcare professional liability insurance Application for Allied and other ...evaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for allied and other miscellanous services.
Professional Liability Insurance application for Adult day careevaj171
We can meet the needs of Healthcare Professionals by tailoring insurance needs to include Professional Liability, General Liability and many more. Here is the application for Adult Day Care.
Professional Liability Insurance Application for Alcohol & Drug Rehabilitationevaj171
Allied Protector Plan offers PL & GL insurance coverage for Allied Healthcare professionals & business entities through AM Best “A” rated Insurance Companies. If you are looking for the alcohol and drug rehabilitation for Adult here is the application.
CV - Modèle pour postuler auprès d'une organisation internationleEmploiPublic
La Délégation aux fonctionnaires internationaux, ministère des Affaires étrangères, publie ce modèle de CV, dans sa boîte à outils destinée aux candidats
Professional Liability insurance application for Counselorevaj171
This document is an application for professional liability insurance for a counselor. It requests information about the applicant's business including name, address, services provided, number of clients, use of certain treatment modalities, referrals from legal entities, risk management procedures, insurance history, and exceptions to standard representations and warranties. The applicant must sign to authorize investigations into their background and attest that all answers are truthful.
Physicians and surgeons professional liability insurance applicationbharatchauhan171
This document contains an application for professional liability insurance. It requests information from applicants such as name, address, medical license details, medical specialty, hospital privileges, procedures performed, claims history, and other practice details. The purpose is to gather information needed to underwrite and potentially provide professional liability insurance to physicians.
This document is a scholarship application form for SIM Global Education. It requests personal details, education history, employment history, and other qualifications from the applicant. The applicant is instructed to submit the completed form along with supporting documents by the specified closing date. Any false information could result in disqualification or revocation of an awarded scholarship. The scholarship is only open to bachelor's degree programs at SIM Global Education.
This document is an application form for renewal of validity for nursing programs from 2015-2016. It requests information about the institution such as contact details, programs offered, student enrollment numbers, facilities, and faculty. The applicant must provide documents like building certificates, staff details, clinical placement agreements, and an affidavit certifying the accuracy of the information. Instructions emphasize submitting complete information by the deadline and that incorrect data could result in penalties or legal action.
This document is a venue staff application form that collects personal and job-related information from applicants. It requests contact details, eligibility to work, disability status, the role and job being applied for, employment history, qualifications, references, and a supporting statement. It collects information on criminal convictions and contains a declaration and consent for background checks. Guidance notes explain how the information will be used, defines disability, and provides information on references and criminal convictions disclosures.
Application form for-trainee_teachers_scheme_-2014vikas panthi
This 4-page document is an application form for a Trainee Teachers Scheme. It requests personal details such as name, date of birth, qualifications, work experience, publications, awards, and contact information for references. The majority of the form focuses on collecting educational details including results from Class 10 through the B.Tech degree as well as information about thesis work, summer training programs, and conferences attended. The final section asks for a declaration of truth from the applicant and provides space for a signature and date.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
This 3 part application form requests personal information, job experience details, and references for a position at the British Council. Part 1 collects contact details. Part 2 focuses on work history and qualifications relevant to the job. Part 3 requests availability, references, and criminal convictions disclosure. Completing the form accurately provides information needed to evaluate candidates for roles at the organization.
Resolution Health Medical Scheme 2014 Membership Application FormResolution Health
This application form must be received within one month of signing or it will be void. Incomplete forms will not be accepted. The applicant must provide personal details, details of dependents to be covered, contact information, previous medical scheme history, income details, and nominated medical practitioners. The form also requires disclosure of any existing medical conditions for the applicant or dependents.
This document is a reimbursement form for ABCDE health plan members. It requests information about the patient and claim, including patient details, other insurance coverage, service provider information, and a description of the medical issue and treatment. Members are instructed to attach an itemized bill and any other necessary documentation, sign the form, and mail it to the claims address provided for processing.
The document outlines a workshop on appealing denials for Synagis referrals. It discusses what information to collect when an office calls about a denial, examples of denial cases, tools to have on hand for appeals, reasons referrals get denied, how to write effective appeal letters, and best practices for handling denials and appeals.
LA County HIV Public Health Fellowship Program Application FormEric Olander
To apply for the Los Angeles County HIV Public Health Services Fellowship Program, interested candidates must submit a letter of interest – including career goals and how the fellowship would help him/her achieve those goals – their curriculum vitae, and a list of references, to:
County of Los Angeles Department of Health Services
Los Angeles County HIV Public Health Fellowship Program
5850 South Main Street, Room 2214
Los Angeles, California, 90003
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
This document appears to be a health insurance claim form containing patient and insurance information. It includes fields for the patient and insured's names, addresses, dates of birth, policy and identification numbers. There are also sections to provide diagnosis codes, procedure codes, dates of service, charges and payments. The form is signed by both the patient and the treating physician to authorize the release of medical information and payment of benefits.
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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1. Practitioner Volunteer / Employment Application
Page 1 of 15
PLEASE:
1. COMPLETE THIS ENTIRE APPLICATION.
2. SUBMIT A COPY AND RETAIN THE ORIGINAL FOR YOUR RECORDS.
3. CURRICULUM VITAE WILL NOT BE ACCEPTED AS REPLACEMENT FOR A PART OF THIS APPLICATION.
4. SIGN AND DATE: ATTESTATION ON PAGE 9 AND/OR 10.
5. SIGN AND DATE: RELEASE OF INFORMATION ON PAGE 11.
I A.
PERSONAL INFORMATION
1.
2.
Name (Last, First, Middle)
Degree/Professional Title
3.
4.
Gender:
Male
Female
Other Names You May Have Used (Maiden, a.k.a., etc.)
5.
6.
Home Address/Street
7. (
)
Home Telephone No.
City/State/Zip
8.
(
)
Home Fax No.
10.
9.
E-mail Address
11.
Date of Birth (Month/Day/Year)
12.
Citizenship/Place of Birth
13.
Languages fluently spoken in addition to English
14.
Languages written in addition to English
15.
Social Security No.
16. If you are not a US Citizen do you have authorization to work in the US?
I B.
Ethnicity (Optional)
Yes No
PRACTICE SPECIALTY FOR WHICH YOU ARE SEEKING AFFILIATION
1. Are you applying as a:
Primary Care Physician:
Family Practice
Internal Medicine
Family Practice with Deliveries
Internal Medicine/Pediatrics
OB/Gyn
Other
Specialist:
Specialty
Sub-Specialty
Allied Health Practitioner:
Nurse Practitioner
Physician Assistant
Clinical Nurse Specialist
Nurse Midwife
Optometrist
Other
2. Other medical interests in practice, research, etc:
Pediatrics
General Practice
Psychologist
Social Worker
1
2. Practitioner Volunteer / Employment Application
Page 2 of 15
COPY THIS PAGE FOR MORE THAN ONE OFFICE
II A. PRIMARY OFFICE PRACTICE INFORMATION:
Information will be published unless box checked:
1. List the health plans this office location accepts:
2. Type of Practice:
Corporation
Hospital Based
Partnership
Hospital Employed
3.
Solo
Institution
Rural/Federal Qualified Health Clinic
4.
Group Practice Name as Appears on SS4 or W-9 Form
Federal Tax ID No.
5.
Address
Suite
City
State
County
Zip
6.
Mailing address if different than above: newsletters, etc.
7. (
)
Telephone No.
8.
(
)
Fax No.
9.
Office E-mail Address
10. (
)
Emergency On-call No.
11. (
)
Beeper No.
12. Internet access:
13.
14. (
)
Telephone No.
Yes No
15. (
)
Fax No.
Office Manager
16.
Billing address where payments are to be sent
Suite
City
State
Zip
17.
Claims Payable to
18.
Languages other than English spoken by staff
19. Medicaid No.
Effective Date
21. List physicians practicing at this location:
20.
Is office Handicap accessible: Yes
No
Specialty:
22. Office Hours:
PRIMARY CARE APPOINTMENT HOURS AVAILABLE
FOR PATIENT CARE
FROM
TO
OFFICE HOURS
FROM
TO
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
23. Indicate the waiting time to obtain an appointment in your office for:
a. Routine visits _____ days
b. Well exams _____ days
24. Do you currently? (Check response)
Place an age limit on your patients?
Minimum Age: ___ Maximum Age: ___
Accept new patients into practice?
Accept new patients by physician referral only?
Place limitation on patient gender?
If “Yes”, please specify limitation:
Male
Female
Yes
c. Urgent problems _____ days
No
Yes
No
Accept Medicare Assignment?
Accept Medicaid Assignment?
Have 24-hour phone coverage?
Have electronic medical record keeping system?
Have capability for electronic billing?
Electronic Billing Code:
2
3. Practitioner Volunteer / Employment Application
Page 3 of 15
25. Do you have an investment or other financial interest in any health care delivery organization? i.e. home health care, lab, managed care
organization, etc. Yes No If yes, describe:
26. List financial partners:
27. Have you “opted out” of Medicare?
Yes No
28. List current accreditations, certifications or special recognitions:
NCQA JCAHO URAC
OTHER:
II B. CROSS COVERAGE [Please list covering practitioners. If additional information, please attach.]
1.
Name of Practitioner
(
)
Telephone No.
Specialty
Address
Suite
City
State
Zip
Hospital Affiliations
2.
Name of Practitioner
(
)
Telephone No.
Specialty
Address
Suite
City
State
Zip
Hospital Affiliations
3.
Name of Practitioner
(
)
Telephone No.
Specialty
Address
Suite
City
State
Zip
Hospital Affiliations
N/A
II C. 24-HOUR COVERAGE AND ADMITTING ARRANGEMENTS
1. Do you have arrangements for 24-hour, 7-days-a-week medical coverage for your patients?
Yes No
If no, please explain:
2. Do you currently admit and care for your hospitalized patients?
arrangement(s) for each inpatient facility:
Yes No
If no, please explain the formal inpatient coverage
N/A
II D. RADIOLOGY
1. Do you perform/provide radiology services in your office?
Yes No
X-ray License No.
If yes, at what site(s):
2. Do you perform mammograms?
Yes No
If yes, attach copy of State of Michigan and FDA certificate.
N/A
II E. DIAGNOSTICS
1. If you provide direct laboratory services, please indicate the Tax ID No. utilized and provide CLIA or COLA information.
Attach a copy of your CLIA or COLA certificate or waiver if you have one:
Tax ID
Billing Name: CLIA / COLA
2. Do you provide in-house Endoscopy procedures?
Type of Service Provided
Yes No
3
4. Practitioner Volunteer / Employment Application
Page 4 of 15
II F. SURGICAL
N/A
1. If you have multiple office locations, which one(s) has a surgical suite(s):
If yes, is it: (check all that apply) State licensed
Medicare Certified
MQC Accredited AAAASF Accredited
Other
ACR/FDA
AAAHC Accredited
2. Other Certifications (e.g. Fluoroscopy, Radiography, etc.)
Type
Number
Expiration
Type
Number
Expiration
N/A
II G. ALLIED HEALTH PRACTITIONER SUPERVISING PHYSICIANS
1.
Name of Supervising Physician
(
)
Telephone No.
Specialty
2.
Address
Suite
City
State
Zip
3.
Hospital Affiliations
III A. MEDICAL / PROFESSIONAL SCHOOL
List all Medical Schools/Institutions attended including undergraduate and graduate school for allied health practitioners. Enclose copies of
your diplomas and certificates.
1.
Medical/Professional School
Degree Awarded
Address
City
Medical/Professional School
Degree Awarded
Address
City
Date of Graduation (mm/yy)
State
Zip
2.
Date of Graduation (mm/yy)
State
Zip
III B. POST GRADUATE TRAINING
List all training attended. Enclose copies of your certificates. Explain any 30-day or greater gap in your training on a separate sheet.
1. INTERNSHIP
Program successfully completed?
Yes No
Institution/Hospital
Address
Program Specialty
Dates From (mm/yy)
City
Program Director
Dates To (mm/yy)
State
Zip
(
)
Telephone No.
4
5. Practitioner Volunteer / Employment Application
2. RESIDENCY
Program successfully completed?
Yes No
Institution/Hospital
Dates From (mm/yy)
Address
City
Program Specialty
3. FELLOWSHIP
Dates To (mm/yy)
State
Zip
(
)
Telephone No.
Program Director
Program successfully completed?
Page 5 of 15
Yes No
Institution/Hospital
Dates From (mm/yy)
Address
City
Program Specialty
Program Director
Dates To (mm/yy)
State
Zip
(
)
Telephone No.
4. OTHER
Program successfully completed?
Yes No
Institution/Hospital
Dates From (mm/yy)
Address
City
Program Specialty
Program Director
Dates To (mm/yy)
State
Zip
(
)
Telephone No.
5
6. Practitioner Volunteer / Employment Application
Page 6 of 15
Directions for Sections IV & V: List in chronological order (with the current affiliation first) all institutions where you have current affiliations
and have had previous hospital privileges. This includes hospitals, residential treatment and rehabilitation centers, surgery centers,
institutions, corporations, military assignments, or government agencies. Work history should include self-employment. If more space is
needed, attach additional sheet(s). A curriculum vitae (CV) is not sufficient as replacement for these sections.
IV.
HOSPITAL / FACILITY HISTORY
1.
CURRENT Primary Admitting Facility
Address
Department/Specialty
Dates From (mm/yy)
Suite
City
Staff Category
State
Dates To (mm/yy)
Zip
(
)
Telephone No.
Chairperson
2.
Admitting Facility
Address
Department/Specialty
Dates From (mm/yy)
Suite
City
Staff Category
State
Dates To (mm/yy)
Zip
(
)
Telephone No.
Chairperson
3.
Admitting Facility
Address
Department/Specialty
Dates From (mm/yy)
Suite
City
Staff Category
State
Dates To (mm/yy)
Zip
(
)
Telephone No.
Chairperson
4.
Admitting Facility
Address
Department/Specialty
V.
Dates From (mm/yy)
Suite
City
Staff Category
State
Dates To (mm/yy)
Zip
(
)
Telephone No.
Chairperson
WORK HISTORY [Add additional sheets if more space required.]
Chronologically list all work history activities since completion of postgraduate training. Explain any gaps of more than thirty days.
1.
Current Practice
Address
Contact Name
Suite
City
Dates From (mm/yy)
State
Zip
Dates To (mm/yy)
(
)
Telephone No.
2.
Previous Practice/Employer
Address
Contact Name
Suite
City
Dates From (mm/yy)
State
Zip
Dates To (mm/yy)
(
)
Telephone No.
3.
Previous Practice/Employer
Address
Contact Name
Suite
City
Dates From (mm/yy)
State
Zip
Dates To (mm/yy)
(
)
Telephone No.
6
7. Practitioner Volunteer / Employment Application
VI.
Page 7 of 15
TIME INTERVALS [Explain any time intervals not accounted for in application.]
Suspended from Practice
From
To
Loss of License
From
To
Served in Military
From
To
Personal Leave
From
To
Other (Please describe)
From
To
VII.
MEDICAL / PROFESSIONAL LICENSURE
1.
State Medical / Professional License No.
Date First Issued
Expiration Date
2.
State Controlled Substance No.
Expiration Date
3.
Drug Enforcement Administration Certification No. (DEA)
Expiration Date
4. ALL OTHER STATE MEDICAL/PROFESSIONAL LICENSES:
State:
License No.:
Expiration Date:
State:
License No.:
Expiration Date:
5.
or N/A
6.
Medicare ID No.
ECFMG No.
7.
8.
UPIN (Unique Physician Identification Number)
VIII.
9.
NPI (National Provider Identifier)
HIPAA Taxonomy Codes
BOARD CERTIFICATION/CERTIFYING ENTITY
Name of Board/Certifying Entity
Certificate No.
Date
Certified /
Re-certified
Expiration Date
Specialty
1.
2.
3.
Have you applied for board certification other than those indicated above?
Yes
No
If yes, list board(s) and date(s):
If not certified, do you intend to apply?
Yes Specify timeframe:
No
Specify reason:
Have you ever taken and not passed a medical board examination?
Yes No
If yes, will you re-take? Yes
No V
7
8. Practitioner Volunteer / Employment Application
IX.
Page 8 of 15
REFERENCES
List three professional references, preferably from your specialty area, not including relatives, and no more than one current partner or
associate. NOTE: References must be from individuals who are directly familiar with your work, either clinical observation or close working
relations.
1.
Name
Address
(
)
Telephone No.
Title/Relationship
City
State
Zip
(
)
Fax No
Zip
(
)
Telephone No.
(
)
Fax No
Zip
(
)
Telephone No.
(
)
Fax No
Email Address:
2.
Name
Address
Title/Relationship
City
State
Email Address:
3.
Name
Address
Title/Relationship
City
State
Email Address:
8
9. Practitioner Volunteer / Employment Application
X.
Page 9 of 15
PROFESSIONAL LIABILITY CARRIER INFORMATION
Please list all of your professional liability carriers for the past ten years:
Does your current professional liability insurance cover you in all of your practice locations? Yes
No
1.
Current Insurance Carrier
Address
Coverage Amount: (Claim/Aggregate)
Initial Date of Coverage
Policy No.
City
State
(
)
Telephone No.
Zip
Type of Coverage
Exclusions from Coverage
Retroactive Date of Coverage
Expiration Date
2.
Insurance Carrier
Address
Coverage Amount: (Claim/Aggregate)
Initial Date of Coverage
Policy No.
City
State
(
)
Telephone No.
Zip
Type of Coverage
Exclusions from Coverage
Retroactive Date of Coverage
Expiration Date
3.
Insurance Carrier
Address
Coverage Amount: (Claim/Aggregate)
Initial Date of Coverage
Policy No.
City
State
(
)
Telephone No.
Zip
Type of Coverage
Exclusions from Coverage
Retroactive Date of Coverage
Expiration Date
4.
Insurance Carrier
Address
Coverage Amount: (Claim/Aggregate)
Initial Date of Coverage
Policy No.
City
State
(
)
Telephone No.
Zip
Type of Coverage
Exclusions from Coverage
Retroactive Date of Coverage
Expiration Date
5.
Insurance Carrier
Address
Coverage Amount: (Claim/Aggregate)
Initial Date of Coverage
Policy No.
City
Type of Coverage
Retroactive Date of Coverage
State
(
)
Telephone No.
Zip
Exclusions from Coverage
Expiration Date
9
10. Practitioner Volunteer / Employment Application
XI.
Page 10 of 15
CLAIM / LAWSUIT HISTORY - 10 YR. HISTORY
If you answer "YES" to any of the following questions, please provide details per the attached claims information
sheet. Please explain any surcharge to your professional liability coverage on a separate sheet.
YES
NO
YES
NO
YES
NO
Have you ever been a defendant in a malpractice suit?
Have any judgments been made against you or settlements been agreed to in any professional liability cases?
Are there any professional liability lawsuits pending against you at the present time?
Has your professional liability insurance ever been terminated or restricted or modified (e.g. reduced limits, restricted
coverage, surcharged), or have you ever been denied professional liability insurance?
XII.
HEALTH STATUS
If the answer to any question is "YES", reference the question on a separate sheet. Please provide a full
explanation and attach.
Are you currently using any chemical substance(s), which in any way may impair or limit your ability to practice medicine
with reasonable skill and safety?
Are you currently engaged in the illegal use of controlled substances?
Do you have a mental or physical condition, which in any way may impair or limit your ability to practice medicine with
reasonable skill and safety with or without reasonable accommodation?
XIII.
PROFESSIONAL PRACTICE
Have any of the following been or are currently in the process of being denied, revoked, not renewed,
suspended, limited, restricted, reviewed, placed on probation, or placed under other disciplinary action, either
voluntarily or involuntarily in this or any other state, territory or country? If “YES”, provide full explanation and
attach.
Medical or professional license
DEA Registration or Controlled Substance license
Hospital medical staff membership
Clinical privileges or other rights on any hospital medical staff
Employment by any hospital, institution or the military
Professional society membership
Participation in any private, federal, or state health insurance program
(i.e. Medicare, CHAMPUS, Medicaid)
Participation in an HMO, PPO, or any other managed care organization
Board Certification
10
11. Practitioner Volunteer / Employment Application
XIV.
Page 11 of 15
OTHER DISCLOSURES
At any time have you ever been:
Convicted of any criminal offense in any jurisdiction
Convicted of a misdemeanor relating to a health profession, or received probation without a verdict, disposition in lieu of
trial, or an accelerated rehabilitation disposition of felony charges in any state, territory or country
Have you ever, at any time, or are you currently:
Under audit by a Health Care Agency (i.e. Medicare, Medicaid, MDCH, or any insurance)
YES
NO
YES
NO
YES
NO
Under indictment for any crime
The subject of an investigation by any private, federal or state health insurance program or state, territory or country
licensing board
The subject of any adverse action reports to a state or federal agency
Sanctioned by a government program or agency for any reason
Have you ever, at any time, either voluntarily or involuntarily:
Withdrawn your application for medical staff membership at any facility
Withdrawn your request for any clinical privileges at any facility
XVII. ATTESTATION STATEMENT
I agree to the contents thereof as evidenced by my signature that the information provided in this
application is true and complete to the best of my knowledge and that omission or falsification of
information may be cause for ineligibility or disaffiliation. I further agree that I have current malpractice
insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
Go To Next Page To Update Attestations
11
12. Practitioner Volunteer / Employment Application
Page 12 of 15
XVIII. UPDATE ATTESTATION STATEMENT
One signature block below is to be signed if a previously completed application is being reviewed and
updated for submission to an additional organization.
The application was designed so that a practitioner need complete it in its entirety only once. If application is then made to another
organization which accepts this Standard Application and it has been more than 60 days since the practitioner completed or updated the
application, the practitioner may review the application, make any needed modifications and then sign one of the attestation statement blocks
below, reconfirming that the application is complete, true and accurate. It is particularly important that the Disclosure Questions be reviewed
and any changes made with appropriate documentation included.
I agree to the contents thereof as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that omission or falsification of information may be cause for ineligibility or disaffiliation. I further agree that I have current
malpractice insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
I agree to the contents thereof as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that omission or falsification of information may be cause for ineligibility or disaffiliation. I further agree that I have current
malpractice insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
I agree to the contents thereof as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that omission or falsification of information may be cause for ineligibility or disaffiliation. I further agree that I have current
malpractice insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
I agree to the contents thereof as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that omission or falsification of information may be cause for ineligibility or disaffiliation. I further agree that I have current
malpractice insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
I agree to the contents thereof as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that omission or falsification of information may be cause for ineligibility or disaffiliation. I further agree that I have current
malpractice insurance and I have disclosed the history of loss or limitation of privileges or disciplinary activity.
Signature:
Date:
12
13. Practitioner Volunteer / Employment Application
Page 13 of 15
CONSENT TO RELEASE OF INFORMATION FORM
I understand that this Consent to Release Information is made in connection with Physician/Practitioner contracting,
credentialing, recredentialing or reappointment activity of the Plan. I further understand that the Plan is responsible for the
evaluation of my professional training, experience, professional conduct and judgment. All information submitted by me or on
my behalf pursuant to this Consent to Release Information is true and complete to the best of my knowledge and belief. I fully
understand that any misstatement in or omission related thereto may constitute cause for the summary dismissal/denial of such
participation in the Plan. I understand and agree that as an applicant for participation with the Plan, I have the burden of
producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications
and for resolving any doubts about such qualifications.
I hereby authorize the Plan and its representative to contact and/or consult with any persons, entities or institutions (including,
but not limited to, hospitals, HMOs, PPOs, other group practices and professional liability carriers) which I have been affiliated,
have used for liability insurance or who may have information relevant to my character and professional competence and
qualifications, whether or not such persons or institutions are listed as references by me. I consent to the release and
communication of information and documents between the Plan and persons, entities or institutions in jurisdictions in which I
have trained, resided, practiced, or applied for professional licensure, privileges or membership in plans for the purpose of
evaluation of my professional training, experience, character, conduct, ethics and judgment, and to determine professional
liability insurance and/or malpractice insurance claims history.
I also authorize and direct persons contacted by the Plan to provide such information regarding my character and/or professional
competence and qualifications, my professional liability insurance and/or malpractice insurance claims history to representatives
of the Plan and I understand in doing so, I am waiving my confidentiality rights to this information. I release and hold harmless
from liability all persons, entities, or institutions who, in good faith and without malice for acts performed in gathering or
exchanging information in this credentialing or recredentialing process. This release and hold harmless provision applies to all
persons, entities and institutions who will provide and/or receive, as part of the Plan's credentialing or recredentialing process,
information which may relate to my past or present physical and/or mental condition, including substance abuse, alcohol
dependency and mental health information.
I further authorize the release of the above information or any other information obtained from the application by a credentialing
verification organization (CVO) to any health care organization designated by me or one that has entered into an agreement with
the CVO where I currently have, am currently applying, or in the future will be applying for participation. I also authorize the
CVO or the Plan to allow my file to be reviewed by the organizations' state or national accrediting and licensing bodies.
I further affirm that I currently do not have any physical and/or mental conditions and/or impairments, such as substance abuse,
alcohol dependency and/or mental health concerns which interfere with my ability to practice medicine. I agree to notify
representatives of the Plan of any changes in my professional licensure, scope of hospital privileges, participating Plan status,
status of my malpractice insurance, malpractice claims history information and practice locations. I understand that this
application shall not be deemed complete until an on-site medical practice office review is completed, if applicable, as well as
receipt of all information required by this application process. I further agree to appear before the Plan for interviews, if
requested, or inquiries regarding evaluations of my professional qualifications at reasonable times and places.
13
14. Practitioner Volunteer / Employment Application
Page 14 of 15
A photocopy of this consent shall be as effective as an original when presented.
Practitioner's Printed Name:
Practitioner's Signature:
Date:
Updated Signature:
Date:
Updated Signature:
Date:
Updated Signature:
Date:
Updated Signature:
Date:
SUPPLEMENTAL CLAIMS INFORMATION FORM
N/A If no claims.
(PLEASE COMPLETE A SEPARATE FORM FOR EACH CLAIM)
14
15. Practitioner Volunteer / Employment Application
Claim Number or Patient Initials:
Incident Is:
You Are:
Age:
Pending
Page 15 of 15
Gender:
Closed Date:
Dismissed Date
Settlement Date
$
Judgment
$
Date
Solo Defendant
Co-Defendant With
Other
Were the Settlement Terms Confidential?
Yes
No
Settlement/Judgment Details:
Amount Paid on Your Behalf:
Date of Incident:
Date Suit Filed:
Court:
Case No.:
Name and Address of Insurance Carrier at Time of Incident:
Name of Additional Defendant(s):
Explain in Detail the Plaintiff's Allegations:
Explain in Detail your Defenses to These Allegations:
Patient's Condition Post-Incident:
Whom may we consult for further legal information about the suit:
Signature of Applicant
Date
Print Name
15