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Zip Application

Filling out Psychiatrists Only’s Zip Application gives us the information we need to start working for you. You will be contacted by one of our recruiters within 1 working day once your application is submitted via e-mail. You may prefer to fax it to us at 800-838-9843. We will require your signature by fax, mail or overnight service in accordance with laws regulating information release of background information. Among the details we must verify:

  • Education
  • Disciplinary action
  • Medicare and Medicaid status
  • Board Certification
  • State licensure
  • Current Professional References

We appreciate your interest in Psychiatrists Only and look forward to identifying the perfect opportunity for you.

Name*:
MD/DO Specialty:
Address*:
City:
 State: ZIP:
Home Phone:
Office Phone:
Email*:
Fax*:
Date of birth:
Place of birth:
Social Security #:
Medical School:
 Graduation Date:
State Licenses:
Board Certified:
 Yes No
Board Eligible: Yes No
Member of APA:
 Yes No
Member local APA: Yes No
If foreign medical school graduate, list ECFMG #:
If your answer to any of the following questions is yes, please attach complete explanation.
Has your license to practice medicine in any jurisdiction ever been involuntarily surrendered, limited, suspended or revoked?

 Yes No
Have you ever voluntarily surrendered, limited or suspended your license to practice medicine in any jurisdiction, under threat of investigation, order of consent invoked by any jurisdiction, or as a settlement to an investigation by a jurisdiction, in lieu of threatened mandated revocation or suspension?

 Yes No
Have you ever been denied a state medical license?

 Yes No
Have you ever been refused membership on a hospital medical staff?

 Yes No
Have you ever voluntarily surrendered, limited or suspended your privileges at any hospital under threat of investigation, order of consent invoked by any hospital or as a settlement to an investigation by a hospital in lieu of threatened mandated revocation or suspension?

 Yes No
Has your request for any specific clinical privilege ever been denied or granted with stated limitations?

 Yes No
Have your privileges at any hospital ever been suspended, diminished, revoked or not renewed?

 Yes No
Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any medical organization?

 Yes No
Has your narcotics registration, state or federal ever been involuntarily diminished, suspended or revoked?

 Yes No
Have you ever voluntarily surrendered your narcotics registration, state or federal, under threat of Investigation, order of consent invoked by any jurisdiction, or as a settlement to an investigation by a jurisdiction in lieu of threatened mandated revocation or suspension?

 Yes No

Have you ever been subject to a Medical Malpractice Claim?

 Yes No
Have you ever been denied, or had your Medical Malpractice insurance revoked or cancelled?

 Yes No
Has your Medicare or Medicaid participation ever been suspended or revoked?

 Yes No
Have you ever been convicted of a felony?

 Yes No
Have you ever received treatment for alcoholism, substance abuse or a psychiatric disorder? Yes No
 
Do you have current professional liability insurance? Yes No Policy #:
Company: Policy Limits:
 
Applicant agrees 1) that the information contained herein and the references obtained and verification received in connection with processing the application may be disclosed to any professional insurance company or healthcare facility making a written request thereof, 2) that all of the information contained herein is true and correct and that if anything contained herein is false, Psychiatrists Only, may immediately terminate any contract entered into with applicant, and 3) that applicant shall notify Psychiatrists Only in writing if any of the answers or information contained herein becomes incorrect or incomplete.

Psychiatrists only and their employees and representatives (collectively referred to as "you") are hereby authorized to consult with the employees and medical staff members of any medical facility with which I have been associated and with such other individuals or organizations including past and present insurance malpractice carriers, state medical boards of which I have been a member or held a license through, private practitioners, hospitals with which I have been associated and medical schools and residency programs I have attended, or others in order to obtain information bearing on my academic record, work record, professional performance or other evaluations. In consideration of the furnishing of the above information, I hereby release and discharge you and any other individuals or organizations providing such information, and any and all persons, employees, representatives or agents of any of the above from any and all liability or claims of any nature in connection with the information furnished hereunder. I further consent to the release of information obtained to your client hospitals, clinics and healthcare providers. I understand that it may be difficult to obtain the background information unless it is solicited in a confidential manner. I understand and agree that I will not have access to this information and I waive any right of access to such information that I may have under the laws of any state or of the United States except as may be required by court order. A copy of this Authorization and Release may be provided to each individual hospital or organization where information on my credentials is sought and shall remain in effect until specifically revoked in writing by me.

I agree to hold all phone calls and discussions between Psychiatrists Only and myself confidential. I will not divulge to any other recruiting or locum tenens companies information concerning clients contacts, pay rates, time or dates of my work with Psychiatrists Only (unless required to do so on a hospital or state license application). I release and allow Psychiatrists Only to present my credentials to clients who are interested in my candidacy for locum tenens positions. Upon acceptance by a client of my credentials for a locum tenens assignment and my acceptance of the assignment with the same client, I agree to immediately complete the full application for the client hospital, clinic, HMO or private practitioner. I also certify that I am a physician possessing the necessary education and training to practice medicine in the states where I am currently licensed.
Physician Name:
Date:
*Please submit a copy of your CV, DEA, State Licenses and Board Certifications.