Pre-Application Questionnaire

Once completed, your pre-application questionnaire will be transmitted to Medical Staff Services.

This document is considered confidential and protected from discovery under California Evidence Code § 1157.

SurveyMonkey is HIPAA compliant.

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* 1. Name of Applicant

Last Name

First Name

Middle Name or Initial

Degree

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* 2. NPI

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* 3. Do you have a California Medical License?

Yes

If you answered NO, when did you apply? (Please answer in mm/dd/yyyy format)

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* 4. Primary Specialty

If not listed above, please enter primary specialty here:

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* 5. Are you Board Certified or Board Eligible?

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* 6. Have you completed residency/fellowship training?

Yes

If NO, what is the date you expect to complete your training?

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* 7. What is the end date of your most recent specialty training?

Date / Time

Date

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* 8. What is the specialty of your most recent training?

If not listed above, please enter primary specialty here:

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* 9. Primary Campus

Mountain View

Los Gatos

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* 10. Anticipated Start Date (If known)

Date

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* 11. Personal Email Address (cannot be a group or practice email)

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* 12. Cell Number

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* 13. I am a Telemedicine Provider

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* 14. Medical Group/Practice Name

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* 15. Credentialing Contact/Office Manager Information (If not applicable, please enter N/A in each field)

Name

Email Address

Phone Number

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* 16. If Allied Health Practitioner, what is the name of your supervising physician?

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* 17. I am applying as a

Physician (MD, DO, DPM, DDS, DMD)

Allied Heath Practitioner (NP, PA, CRNA, CNM, RNFA, CCP, PhD, PsyD, RDA, CNOR, CST)

Medical Student

Fellow

Resident

Student Certified Nurse Midwife

Student Registered Nurse Anesthetist