Full Name:

Title

Email:

Cell Number:

A. GENERAL INFORMATION:

Clinical Specialty/Sub-specialty:

2. Describe case types and volume you wish to bring to Texas Surgical Hospital

Group Name:

Anticipated Start Date:

Credentialing Contact Name:

Phone:

Email:

Fax:

Are there presently, or previously any disciplinary proceedings or investigations taking place at any hospital, Healthcare facility, or organization, relating to your clinical competence or professional conduct?

YESNO

Have you had any recent, or previously experienced significant physical or mental health problems or had involvement with substance abuse including drugs or alcohol?

YESNO

Have any professional liability suits ever been filed against you?

YESNO

Are there presently any professional liability suits pending against you?

YESNO

I hereby certify that I am in good health and am capable of providing competent and continuous care of my patients.

YESNO