Apply to Join Pioneer Medical Group

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CONTACT INFORMATION

Position Applying For*

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Please feel free to upload your current Non-Compete Contract, if you would like our team to review.

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Email*

Title*

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First Name*

Middle Initial

Last Name*

Suffix*

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Former Name

You may enter one or multiple previously used names, including legal names or nicknames, by separating them with commas

Primary Phone*

Secondary Phone

Country*

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Address 1*

Address 2

City*

State*

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Zip / Postal Code*

PREVIOUS EMPLOYMENT

Previous / Current Employment - Company Name*

Job Title*

From Date*

To Date*

Reason for Leaving*

May we contact your previous supervisor for a reference?*

Yes

Do you Have a Current Non-Compete*

Yes

LICENSES AND CERTIFICATIONS

Licenses / Certification Name and License Number*

QUESTIONS

If Other, Explain*

Who referred you?*

Have you ever worked or Applied for this Company?*

Yes

Are you eligible to work in the US?*

Yes

Do you require sponsorship?*

Yes

If yes, what type?*

When are you available to start?*

What is your Desired Salary?*

Are you Board Certified?*

Yes

Eligible

Specialty Board Certified in?*

Certifying Board Name?

Do you currently hold a Florida Medical License?*

Yes

Applied

What type of EMR systems have you used in your previous positions?*

PHYSICIAN QUESTIONNAIRE

Please identify all states in which you hold or have held a medical license.*

Is your DEA Current*

Yes

Not Applicable

Has your permit to dispense or prescribe drugs been limited, suspended, revoked, placed on probation or been voluntarily surrendered in any state?*

Yes

If yes, what restrictions do you have on your DEA?*

Have you practiced continuously since completing your residency training program?*

Yes

If no, please explain below*

Have you ever had professional liability insurance refused, declined, non-renewed, cancelled or accepted on special terms?*

Yes

If yes, please explain below*

Have any claims related to your practice of medicine been made against you?*

Yes

If yes, please explain below*

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action, in any practice, local, state, or national professional organization, including specialty boards?*

Yes

If yes, please explain below*

Have you ever been excluded from Medicare or any other governmental program?*

Yes

If yes, please explain below*

Have your license to practice in any jurisdiction ever been denied, limited, suspended, or revoked?*

Yes

If yes, please explain below*

Have you ever been convicted of a felony?*

Yes

If yes, please explain below*

Did you spend any additional years in a residency?*

Yes

If yes, please explain below*

Have your clinical privileges or staff membership at any hospital, managed care organization or other healthcare institution ever been revoked, suspended, reduced, or not renewed; or is any proceeding pending, or has any proceeding been instituted that, if decided adversely to you, would result in any of the foregoing; or has an application for membership or clinical privileges ever been denied or granted with stated limitations?*

Yes

If yes, please explain below*

Have you been notified to respond to, appear before or been investigated by any licensing or regulatory agency on a complaint of any nature, including, but not limited to, unprofessional or unethical conduct?*

Yes

If yes, please explain below*

Have you ever pled “guilty” or “no contest” to, or been convited of a crime?*

Yes

If yes, please explain below*

Has any state or federal, civil or criminal judgment or settlement ever been made against you?*

Yes

If yes, please explain below*

Have you ever been fired or asked to leave a job?*

Yes

If yes, please explain below*

Have you ever had a complaint of sexual harassment filed against you?*

Yes

If yes, please explain below*

Have you ever received notification from a government agency regarding fraud or abuse allegations or other violations of the Medicare program?*

Yes

If yes, please explain below*

Have you ever been excluded from Medicare or any other governmental program?*

Yes

If yes, please explain below*

EEOC - Voluntary Self-Identification Survey

This employer is required to notify all applicants of their rights pursuant to federal labor laws. For further information, please review this notice from the Department of Labor: EEO is the Law poster www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm You may have additional rights pursuant to recent amendments to federal labor laws. Please review these protections from the EEO is the Law Supplement: www.eeoc.gov/employers/upload/eeoc_gina_supplement.pdf This employer is subject to certain nondiscrimination and/or affirmative action recordkeeping and reporting requirements which require the employer to invite applicants to voluntarily self-identify their race/ethnicity and gender.

Gender*

Male

Female

I decline to say

Ethnic Origin*

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin regardless of race. White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Hispanic or Latino

White (Not Hispanic or Latino):

Black or African American (Not Hispanic or Latino):

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino):

Asian (Not Hispanic or Latino):

American Indian or Alaskan Native (Not Hispanic or Latino):

Two or more races (Not Hispanic or Latino):

Veteran Status

We ask all candidates to provide the information listed below. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information you provide will be kept confidential and may only be used in accordance with applicable federal, state, and local laws and regulations.

Are you a protected Veteran?*

Yes

I decline to say

Voluntary Self-Identification of Disability

Voluntary Self-Identification of Disability*

Yes, I have a disability

No, I don't have a disability

I don't wish to answer

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

REFERENCES

Minimum of 3 references are required

Reference 1 Name:*

Cell Phone:*

Email Address:*

Reference 2 Name:*

Cell Phone.*

Email Address*

Reference 3 Name:*

Cell Phone*

Email Address.*

Covid-19

Are you vaccinated?*

Have you received a Covid-19 vaccine?

Yes

Comment/Explanation*

Signature*

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