University of Rochester Medical Center Dermatopathology Graduate Medical Education Application

First Name

Last Name

Previous Last Name

Street Address

City

State

Zip Code

Country

Street Address

City

State

Zip Code

Country

Cell Phone

Email Address

Home Phone

USMLE ID

AAMC Number

AOA ID

NBOME ID

Are you certified by ECFMG?

ECFMG Number

National Provider Identifier Number (NPI)

Gender

Birth Date

Place of Birth

Country of Citizenship

What is your US citizenship status?

Current Visa Type if applicable

Self-Identification

USMLE Step 1

3 Digit score

Date

USMLE Step 2 (Clinical Knowledge)

3 Digit score

Date

USMLE Step 2 (Clinical Skills)

3 Digit score

Date

USMLE Step 3

3 Digit score

Date

Osteopathic - COMLEX Part 1

3 Digit Score

Date

Osteopathic - COMLEX Part 2 CE (Cognitive Examination)

3 Digit Score

Date

Osteopathic - COMLEX Part 2 PE (Performance Evaluation)

3 Digit Score

Date

Osteopathic - COMLEX Part 3

3 Digit Score

Date

ACLS

ACLS Expiration Date

PALS

PALS Expiration Date

Are you Board Certified?

Which Board?

Were you ever named in a malpractice suit?

Do you have a state medical license?

State:

License Number:

Expiration Date:

DEA Registration

DEA Registration Number

Institution Name

Institution Location

Start Date

End Date

Degree Earned:

If Other, Please Specify Degree:

Date Degree Awarded

Was your medical education or training extended or interrupted?

If yes, please provide an explanation:

Please Specify Awards and Honors

Please Specify Professional Memberships

Institution & Location

Start Date

End Date

Degree Earned

Date Degree Awarded:

Program of Study/Specialization:

Institution & Location

Start Date

End Date

Degree Earned

Date Degree Awarded:

Program of Study/Specialization:

Experience/Specialty:

Institution & Location:

Name of Program Director:

Start Date

End Date

Number of years of training:

Add More Medical Training

Experience/Specialty:

Institution & Location:

Name of Program Director:

Start Date

End Date

Number of years of training:

Add More Medical Training

Experience/Specialty:

Institution & Location:

Name of Program Director:

Start Date

End Date

Number of years of training:

Position

Name of Hospital/Practice:

City, State, Country:

Start Date

End Date

Add more Clinical Work Experience?

Position

Name of Hospital/Practice:

City, State, Country:

Start Date

End Date

Add more Clinical Work Experience?

Position

Name of Hospital/Practice:

City, State, Country:

Start Date

End Date

Publications:

Languages:

Hobbies and Interests

Other Awards/Accomplishments

Have you ever been reported to the National Practitioner Data Bank, Healthcare Integrity and/or Protection Data Bank?

Please Elaborate on your answer

Has your employment, medical staff appointment, panel participation, affiliation or clinical privileges ever been voluntarily or involuntarily suspended, diminished,
revoked, refused or limited in any hospital, health care facility or managed care
organization, IPA or PPO including to avoid disciplinary action for reasons related to
professional competence or conduct?

Please elaborate on your answer

Has your license to practice your profession in any jurisdiction every been limited, restricted, suspended, revoked, denied or subject to probationary conditions?

Please elaborate on your answer

Have you ever voluntarily or involuntarily relinquished your license to practice your profession in any state?

Please elaborate on your answer

Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal or state health insurance program (including Medicare, Medicaid or a managed care organization)?

Please elaborate on your answer

Has your narcotics registration certificate ever been voluntarily or involuntarily limited, restricted, denied renewal, suspended or revoked?

Please elaborate on your answer

Have you ever been denied membership, membership renewal or been subject to any professional review, censure or reprimand in any medical organization or professional society - local, state or national?

Please elaborate on your answer

Have you ever been subject to disciplinary action by a state agency or professional body (i.e., Medical Society, IPRO, OPMC)?

Please elaborate on your answer

Has your specialty board certification or qualification ever been voluntarily or involuntarily denied, revoked, relinquished, not renewed, suspended or reduced?

Please elaborate on your answer

Do you have any pending misconduct charges against you in this state or any other state?

Please elaborate on your answer

Have you ever been convicted of a misdemeanor or felony in any jurisdiction? ..

Please elaborate on your answer

Are you presently or have you ever been subject to any suspension, revocation, discontinuance, limitation, restriction, monitoring or probationary proceedings?

Please elaborate on your answer

Have you ever been cited for violation of patient rights as set forth by the Federal Law and/or NYS Department of Health or any other state department of health?

Please elaborate on your answer

Has your professional liability insurance coverage ever been denied or not renewed by action of any insurance company?

Please elaborate on your answer

Has your professional liability insurance coverage ever been surcharged, suspended or terminated by action of any insurance company?

Please elaborate on your answer

Has your present professional liability insurance carrier excluded any specific procedures from your coverage?

Please elaborate on your answer

Have any professional liability suits been filed against you which are currently pending in this or any other state?

Please elaborate on your answer

Have any professional liability judgments and/or settlements ever been made against you or on your behalf?

Please elaborate on your answer

I certify that my answers are true and complete to the best of my knowledge.

I agree to update this form while it is being processed, should there be any change in the information provided.

I understand that any misrepresentation, misstatement or omission on this form could result in revocation of any privileges/employment granted and subject to reporting according to NYS regulations.

I am not currently using any illegal drug, nor have I during the past two years.

I authorize release of reference information by all past and present employers/educational institutions

Signature

Applicant Name(Printed)

Date of Completion