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Physician Pre-qualification
Thank you for expressing interest in a physician opportunity with Texas Health Resources.

To help us serve you better, please complete all fields in the questionnaire below and click the Submit button.

A Texas Health physician recruiter will review your information and contact you about next steps.

* Indicates required information
---------- Candidate Contact Info ---------- 
First Name * 
Last Name * 
Street Address * 
City * 
State * 
Zip * 
Home Phone 
Cell Phone * 
Email Address * 
Specialty/Current Status * 
Preferred Contact Times/Days * 
---------- Candidate Self-disclosure Questions ---------- 
1. What is your timeline to relocate to Texas
or to join Texas Health? * 
2. If not currently in residency/fellowship, have
you been actively practicing for the last 2 years? 
3. If currently working, what is your notice
obligation to current employer? * 
4. If currently working in the DFW market, do you
have a no-compete clause in your contract? 
5. Are you legally eligible to work in the United States? * 
6. Have you had any malpractice claims in the
past 10 years? If Yes, answer A-E below * 
--- A. Date of occurrence  Calendar (mm/dd/yyyy)
--- B. Amount paid/in reserve to resolve claim 
--- C. Institution involved 
--- D. Current status of claim 
--- E. Details of allegations 
7. Has your professional license or registration
ever been terminated, stipulated, restricted, limited,
conditioned or suspended by any licensing board of a
health-related agency, or is there a review pending? * 
8. Has your DEA registration ever been revoked,
suspended, limited, or conditioned? Or, is there
a review pending? * 
9. Has your membership, participation, clinical
privileges, or employment ever been denied, terminated,
restricted, limited or not renewed? Or is there
a review pending? * 
10. Have you ever been reprimanded, censored,
or otherwise disciplined by any licensing board,
peer-review organization, third-party payer,
clinic, hospital or medical staff? * 
11. Has your certification or participation
in any private, federal or state health insurance
program ever been revoked or restricted,
or is any investigation presently underway? * 
12. Do you face any current or pending charges
or have you ever been indicted or found guilty of
a felony, misdemeanor (other than minor traffic
violation), or other offense involving fraud,
misrepresentation, dishonesty or deceit? * 
13. Have you ever been accused or found guilty
of sexual impropriety or misconduct or
sexual harassment? * 
14. Has your professional liability carrier ever
refused or canceled your coverage? * 
---------- Board Certification Information ---------- 
1. Are you currently Board Certified? 
--- A. Indicate specialty 
--- B. Date that Board Certification expires   Calendar (mm/dd/yyyy)
2. If you are not Board Certified, are you eligible
to sit for the exam? 
--- A. Specialty 
--- B. Date eligibility expires:  Calendar (mm/dd/yyyy)
---------- Texas Licensure Information ---------- 
1. Do you currently have an active Texas license? * 
2. If you have an active Texas license, do you
have an active DPS permit? * 
3. Do you have an active DEA permit? * 
4. If you do not have a Texas license, have
you applied for one? 
--- A. On what date did you submit
your application to the Texas Medical Board? 
Calendar (mm/dd/yyyy)
--- B. Have you been credentialed
previously by FCVS? 
5. Do you have an active license in any
state other than Texas? * 
--- A. If Yes, list the states in which you
have an active license. 
---------- Recruiter Info ---------- 
My Texas Health recruiter is 
---------- Candidate Affirmation ---------- 
I hereby certify that all the answers on this
questionnaire are complete, true and accurate. * 

Authentication * 

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