Physician Information Form
Service Date (Start)
Service Date (End)
1. Physician's Full Name
2a. Work Address
2b. Cell Phone
2c. Email Address
2d. Applying for a temporary license and need a Certificate of Insurance. ( If Yes, We will email you a copy of a Malpractice certificate )
3. Medical Specialty
4. Are you board certified in your specialty?
If No, are you eligible?
5. License Number
-- Select --
District Of Columbia
Permanent or Temporary
-- Select --
* Please verify that your current state license will not expire while at camp. If so, please provide a copy of your renewed license as soon as possible.
6. What are your specific responsibilities and duties in regard to the work you will perform for the camp?
7. Do you plan on performing any surgery on behalf of the camp?
8. Do you plan to administer any anesthesia on behalf of the camp?
9. Have you ever had a malpractice claim or suit filed against you?
10. Have you ever had your license revoked, suspended, restricted, or placed on probation?
11a. Have you ever been the subject of an investigatory or disciplinary proceeding or reprimand?
11b. Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offense?
11c. Have you ever been treated for alcoholism or drug addiction?
12. The name of your malpractice insurer (if none, indicate accordingly):
13. Does this Malpractice Policy cover you for your acts at the camp?
To the best of my knowledge, all of the information I have provided is accurate.
This form was completed by:
Thank you for completing the Physician Information Form.
Directions to 209 Main Avenue, Hawley, PA, 18428
570.226.4571 | 570.226.1105
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