UM Rehab & Ortho: New Application Request for Medical Staff Membership

UM Rehab & Ortho: New Application Request for Medical Staff Membership

Filling up this form allows us to send you the full application via MD Staff.

Applicant's name (as on the Maryland MedicLicense)*

Degree (MD/DO/PA-C/NP/CRNA/PsyD etc.)

Anticipated start date

Please do not perform any clinical activity until you have received an e mail confirming that UM Rehab & Ortho's Board of Directors has approved your application.

Who referred you to UM Rehab & Ortho?

Primary e mail address*

Alternate e mail address

Telephone number

Phone

Date of birth*

NPI number*

Clinical Specialty*

Appointment type requested*

Attending Faculty (Physician, Clinical Psychologist, Podiatrist)

Allied Health Professional (NP, PA-C, CRNA, RNFA, LA-C)

Applicant's employer*

Select or enter value

Other Employer

Current affiliation at another UMMS (yes/no)

Select

Will you have malpractice coverage by MMCIP (Maryland Medicine Comprehensive Insurance Program)?

Select or enter value

Will applicant have private malpractice insurance coverage?

Select or enter value

Malpractice ins coverage

Requestor's name (if different from applicant)

Requestor's e mail address

Please upload your current CV*

Drag and drop files here or

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