Candidate Release & Background Form Candidate Release & Background Form * I Agree: As part of the process, KCA Firm, LLC requires this form to be completed and returned before the interview process can begin. All offers from KCA Firm, LLC clients are contingent upon receiving this Candidate Release and Background Information form and at least three (3) references. * I agree: I hereby consent to the Company’s verifying all the information I have provided on my application form. I also agree to execute as a condition of employment or a condition of continued employment any additional written authorization necessary for KCA to obtain access to and copies of records pertaining to this information. This includes gathering information from the Internet, past employers, and state boards. I authorize KCA Firm, LLC to verify any information contained on my curriculum vitae, background form and referencing paperwork. With regard to the foregoing disclosures, I hereby agree to release KCA Firm, LLC, and its owners, employees, including any person, company, or other entity from any and all causes of action that may arise from your recruitment process with KCA FIRM, LLC or its clients and any use of any information that you provide to KCA Firm, LLC and its clients. I understand that any false answers or statements, will be sufficient for rejection of my application or for my immediate discharge should such falsification or misrepresentations be discovered after I am employed. I agree to allow KCA Firm, LLC to share this information with its clients. * I agree: Information gathered during this search my include information about my training, work history, education, previous work experience, malpractice claims, privileging and licensing information as well as criminal history and I release KCA Firm, LLC from any liability that may arise from the release of this information. I agree that I have read this disclosure and agree that KCA Firm, LLC may contact me regarding opportunities it represents. I understand I can request a copy of this paperwork by submitting a written request to [email protected] I agree that digital or photocopies of this information shall be accepted as the original. * *Digital Signature Agreement. By checking this box I certify that I am the person completing this form and have typed my name below. Name* First Middle Last Please include your middle name.Other Name, Former Name or Maiden Name First Middle Last If you have ever used another name, please include it here.Date* MM slash DD slash YYYY Have you ever worked for the organization and/or health system that you are applying for?* Yes No If so, please elaborate below:* Please add specifics such as date, location, and role in the organization.Are you currently board certified?* Yes No If board certified, please specify all of your specialty certifications/expiration date* Please add specifics such as type of certification and expiration dates or any other relevant information. Ex: American Board of Family Medicine, expires 1/11/23If not board certified, how many times have you sat for the board exam? Please specify if board eligible/date planning to take certification exam:* Please add specifics such as type of certification sitting for and if you have registered and when. Please include if you are not board eligible or any other relevant information. Date available to start your new position MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Please answer the questions below:You may submit additional information and supporting documents via email to [email protected] Do you have any malpractice cases that have been settled in your career or any pending cases? If Yes, please provide details, dates, and settlement amount.* Yes No Upload Supporting Documentation Drop files here or Select files Max. file size: 25 MB. Date of malpractice case* MM slash DD slash YYYY Settlement Details*Do you have other malpractice cases to input?* Yes No Date of malpractice case* MM slash DD slash YYYY Settlement Details*Date of malpractice case MM slash DD slash YYYY Settlement DetailsDate of malpractice case MM slash DD slash YYYY Settlement DetailsDate of malpractice case MM slash DD slash YYYY Settlement DetailsDate of malpractice case MM slash DD slash YYYY Settlement DetailsHave you ever been subject to any civil or criminal litigation or is any pending? If Yes, please explain below.* Yes No Please give us details.*Have you ever been required to appear before any state or federal licensing agency or had a complaint of any nature? If Yes, please explain below.* Yes No Please provide details.*Have you ever had your hospital privileges involuntarily surrendered, limited, revoked, suspended or denied? If Yes, please explain below.* Yes No Please explain the details.*Have you ever had your medical staff privileges voluntarily or involuntarily surrendered or have your privileges ever been surrendered, limited, suspended, revoked or denied? If Yes, please explain below.* Yes No Please explain the details.*Have you had your DEA voluntarily or involuntarily surrendered, limited, suspended, revoked, or denied? If Yes, please explain below.* Yes No Please explain details*Have you ever been subject to discipline or denied membership by any medical organization? If Yes, please explain below.* Yes No Please give us details.*Have you ever been denied medical liability insurance or medical liability insurance renewal? If Yes, please explain below.* Yes No Please explain the details.*Have you ever abused prescription drugs, used illegal drugs, or had issues with alcohol (abuse, reprimand, enrollment in a program)? If Yes, please explain below.* Yes No Please explain the details.*Have you ever been arrested or charged with driving under the influence or a similar charge? If Yes, please explain below.* Yes No Please explain the details.*Have you filed for bankruptcy in the last ten years?* Yes No Please give us some details.*Do you have any reason to believe that you may not be able to get credentialed?* Yes No Please give us some details.*If needed, please add any additional supporting documents here Drop files here or Select files Max. file size: 80 MB.
