DISASTER PRIVILEGES APPLICATION FORM  
• Department:     Specialty:     Subspecialty: 
   
 
VITAL:
Last Name:
 First Name:
 Middle Name:
Degree:
 Email:
 Pager:
 
HOME INFORMATION:
Street Address:
 City:
State:
 ZIP:
 Telephone#:
 
PERSONAL:
Date of Birth:
 Social Security #:
 Gender
 NPI
 
PROFESSIONAL OFFICE ADDRESS:
Street Address:
 City:
State:
 ZIP:
 Phone #:
 Fax #:
 
BOARD CERTIFICATION:
Board/Subspecialty Board:
 Certified Date:
 Expir. Date:
 Recert. Date:
 
HOSPITALS:
Primary Hospital Name:
 City:
 Phone #:
 Fax #:
 
PEER REFERENCE: (Name of Service Chief at Primary Hospital)
Chief's Name:
 Email:
 Phone #:
 Fax #:
 
CREDENTIALS:
Name of Professional School:
 Date of Graduation:
 
PROFESSIONAL LICENSE / DEA CERTIFICATE:
CA Professional License #:
 CA Lic Expir. Date:
 DEA #:
 DEA Expir. Date:
Out of State Lic #:
 Name of State:
 Out Of State Lic Expir. Date:
  
 
PROFESSIONAL LIABILITY:
Company Name:
 Phone #:
 Fax #:
Policy #:
 Expiration Date:
 Amounts:
   
   
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