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.

Question Title

1. Name of Applicant (Required.)

Last Name

First Name

Middle Name or Initial

Degree

Question Title

2. NPI (Required.)

Question Title

3. Do you have a California Medical License? (Required.)

Yes

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

Question Title

4. Primary Specialty (Required.)

If not listed above, please enter primary specialty here:

Question Title

5. Are you Board Certified or Board Eligible? (Required.)

Question Title

6. Have you completed residency/fellowship training? (Required.)

Yes

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

Question Title

7. What is the end date of your most recent specialty training? (Required.)

Date / Time

Date

Question Title

8. What is the specialty of your most recent training? (Required.)

If not listed above, please enter primary specialty here:

Question Title

9. Primary Campus (Required.)

Mountain View

Los Gatos

Question Title

10. Anticipated Start Date (If known)

Date

Question Title

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

Question Title

12. Cell Number (Required.)

Question Title

13. I am a Telemedicine Provider (Required.)

Question Title

14. Medical Group/Practice Name (Required.)

Question Title

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

Name

Email Address

Phone Number

Question Title

16. If you are an Allied Health Practitioner, what is the name of your supervising physician? (If not applicable, please enter N/A in each field) (Required.)

Question Title

17. If you are an Allied Health Practitioner, please enter the following supervising physician information: (If not applicable, please enter N/A in each field) (Required.)

Email Address

Phone Number

Question Title

18. I am applying as a (Required.)

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

Pre-Application Questionnaire

Question Title

* 1. Name of Applicant (Required.)

Question Title

* 2. NPI (Required.)

Question Title

* 3. Do you have a California Medical License? (Required.)

Question Title

* 4. Primary Specialty (Required.)

Question Title

* 5. Are you Board Certified or Board Eligible? (Required.)

Question Title

* 6. Have you completed residency/fellowship training? (Required.)

Question Title

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

Question Title

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

Question Title

* 9. Primary Campus (Required.)

Question Title

* 10. Anticipated Start Date (If known)

Question Title

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

Question Title

* 12. Cell Number (Required.)

Question Title

* 13. I am a Telemedicine Provider (Required.)

Question Title

* 14. Medical Group/Practice Name (Required.)

Question Title

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

Question Title

* 16. If you are an Allied Health Practitioner, what is the name of your supervising physician? (If not applicable, please enter N/A in each field) (Required.)

Question Title

* 17. If you are an Allied Health Practitioner, please enter the following supervising physician information: (If not applicable, please enter N/A in each field) (Required.)

Question Title

* 18. I am applying as a (Required.)

1. Name of Applicant (Required.)

2. NPI (Required.)

3. Do you have a California Medical License? (Required.)

4. Primary Specialty (Required.)

5. Are you Board Certified or Board Eligible? (Required.)

6. Have you completed residency/fellowship training? (Required.)

7. What is the end date of your most recent specialty training? (Required.)

8. What is the specialty of your most recent training? (Required.)

9. Primary Campus (Required.)

10. Anticipated Start Date (If known)

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

12. Cell Number (Required.)

13. I am a Telemedicine Provider (Required.)

14. Medical Group/Practice Name (Required.)

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

16. If you are an Allied Health Practitioner, what is the name of your supervising physician? (If not applicable, please enter N/A in each field) (Required.)

17. If you are an Allied Health Practitioner, please enter the following supervising physician information: (If not applicable, please enter N/A in each field) (Required.)

18. I am applying as a (Required.)