Physician Application Please enable JavaScript in your browser to complete this form.Thank you for your interest in a career opportunity at Columbus Regional Health*. We are honored to be considered by you as your next clinical partner. Answering “YES” to any of the following screening questions will not automatically disqualify you from joining Columbus Regional Hospital or Columbus Regional Health Physicians, LLC, but may require additional explanation. Please include any necessary explanatory documents. * Columbus Regional Health is comprised of Columbus Regional Hospital and Columbus Regional Health Physicians, LLC. Please Indicate Your SpecialtyChooseAddiction MedicineAllergy and ImmunologyAnesthesiologyBariatric SurgeryBreast SurgeryCardiology (General and Interventional)Cardiothoracic SurgeryCritical Care MedicineDentistryDermatologyEmergency MedicineEndocrinologyFamily MedicineGastroenterologyGeneral SurgeryGeriatric MedicineHospice / Palliative CareHematology and Medical OncologyHospitalist (Adult)Hospitalist (Pediatric)Infectious DiseaseInternal MedicineNephrologyNeurologyObstetrics and GynecologyOccupational MedicineOphthalmologyOral and Maxillofacial SurgeryOrthopedic SurgeryOtolaryngology / ENTPain MedicinePathologyPediatricsPhysical Medicine and RehabilitationPlastic and Reconstructive SurgeryPodiatryPsychiatryPulmonologyRadiation OncologyRadiologyRheumatologySpine SurgeryUrgent CareUrologyVascular Surgery(1) Have any disciplinary actions or investigations been initiated or are there any pending against you by any State licensure board or health care facility at which you have been credentialed? If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (2) Has your license to practice in any state ever been relinquished, denied, limited, suspended, revoked, or surrendered? If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (3) Has your eligibility to participate in private, federal, or state health insurance programs ever been suspended or revoked? (for example Medicare or Medicaid?) If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (4) Has your DEA and / or CSR ever been relinquished, limited, suspended, revoked, or voluntarily relinquished? If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (5) Has your employment, Medical Staff appointment, or clinical privileges ever been suspended, revoked, refused, denied, or limited (except for failure to complete medical records) at any hospital or other health care facility? If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (6) Have you been convicted of any felony, misdemeanor or named as a defendant in any criminal proceedings? If yes, please explain. *YesNoExplanationAttach explanatory documents, if any Click or drag files to this area to upload. You can upload up to 3 files. (7) Have you had clinical activity in your primary area of practice within the last two years? *YesNo(8) Are you board certified? If not, board eligible? *Board certifiedBoard eligibleNeitherWhen was the date of initial certification?When is the date of expiration?When will you be completing your certifying exam? (9) Do you have a current contract that contains a non-compete agreement? *YesNoI agree to provide Columbus Regional Hospital and/or Columbus Regional Health Physicians, LLC with updated information regarding all questions on this screening questionnaire as new information becomes available. I also agree to provide Columbus Regional Hospital and/or Columbus Regional Health Physicians, LLC with new additional information that one of its authorized representatives may request. I also authorize Columbus Regional Hospital and/or Columbus Regional Health Physicians, LLC to obtain references on my qualifications. I attest that the information I have provided is accurate and truthful to the best of my knowledge. *I agreeName *FirstLastEmail *PhoneComment or Message *Please attach your CVSubmit