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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.
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.)
Date / Time
8.What is the specialty of your most recent training?(Required.)
9.Primary Campus(Required.)
10.Anticipated Start Date (If known)
Date
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.)
19.I am applying to join the following (select all that apply):(Required.)
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