*Denotes required information
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*Please indicate the Sentara Hospital Medical Staff to which you are applying: (Select all that apply - Hold down the Ctrl button to make more than one selection)
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*Applicant Type (MD, DO, etc.)
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*Residency Completed
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Fellowship Completed
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Allied Health Professionals
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If you are an Allied Health Professional, please provide the name(s) of your sponsoring or supervising physician(s).
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Please provide the information requested below for any additional individuals who may be providing assistance to you in completing your application. If there are no others, skip this section and complete the following sections.
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If you are applying to work at Sentara through a locum tenens agency, please provide the information requested below.
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Board Certification Information
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If No, indicate the year residency/ or fellowship was completed
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*If the applicant is a physician, oral surgeon or podiatrist, is the applicant certified by a specialty board recognized by the American Board of Medical Specialties or the American Osteopathic Association, or by the American Board of Podiatric Surgery or the American Board of Oral and Maxillofacial Surgery?
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1. Has the applicant ever been convicted of or entered a plea of guilty or no contest to any felony or any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence?
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2. Has the applicant ever been excluded or precluded from participation in Medicare, Medicaid or other federal or state governmental healthcare programs?
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3. Has the applicant ever been convicted of Medicare, Medicaid or any other governmental or third party payer programs of fraud or program abuse or has the applicant paid civil money penalties for same?
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4. Has the applicant ever had his or her Medical Staff appointment or clinical privileges denied, revoked, relinquished or terminated by any healthcare facility or health plan for reasons related to clinical competence or professional conduct?
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5. Has the applicant ever had a license to practice revoked or suspended by any state licensing agency?
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For additional information or questions about an application, please contact us at:
Sentara Hospitals Credentialing Office
600 Gresham Drive, 7B
Norfolk, VA 23507
757-388-6175
Email: hospitalcredentials@sentara.com
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