Medical Staff Application Question Title * 1. Name: (Required.) Question Title * 2. Email: (Required.) Question Title * 3. Phone Number (Required.) Question Title * 4. Address (Required.) Question Title * 5. Desired Position/Role: (check all that apply) (Required.) Medical Assistant Registered Nurse Technician Administrative Nurse Practitioner Physician Assistant Other (please specify) Question Title * 6. Preferred Assignment Type (Required.) Temporary Contract Permanent Question Title * 7. Do you consent to a background check? (Required.) Yes No Question Title * 8. Do you consent to credential verification? (Required.) Yes No Question Title * 9. Desired hourly rate (Required.) $17.87/hr $120/hr Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 10. Are you available for immediate placement? (Required.) Yes No Other (please specify) Question Title * 11. Preferred Assignment Duration (Required.) Short-term (less than 3 months) Medium-term (3-6 months) Long-term (more than 6 months) Question Title * 12. Are you fluent in a language other than English? If so, please specify below. (Required.) Yes No Other language(s) (please specify) Question Title * 13. Do you agree to maintain confidentiality and adhere to privacy regulations (HIPAA)? (Required.) Yes No Question Title * 14. Do you agree to maintain high standards of professional conduct and respect for patients, staff, and facilities? (Required.) Yes No Question Title * 15. Do you carry the required liability insurance (if applicable) Yes No Question Title * 16. Please upload resume (Required.) Done
