Resident Application for Malpractice Insurance Sponsorship

In an effort to support rural communities and access to healthcare in Kansas, the Kansas Locum Tenens (KLT) program provides temporary coverage for medical physicians.

Resident physicians have the opportunity for their malpratice insurance to be paid for through the Malpractice Insurance Sponsorship fund (taxes applicable).

Recipients of Malpractice Insurance Sponsorship agree to complete KLT coverages. See the policies and procedures for more information.

Name (first, M.I., last, maiden):

Employee ID Number:

Residency program:

Date of Completion:

Current Program level:

Present address (number & street, city, state, zip):

Preferred e-mail address:
(please be specific, i.e: tsmith@kumc.edu)

Telephone (cell):

Telephone (home):

License number:

Date issued:

Date expires:

DEA Certificate Number:

DEA Expiration Date:

Current Malpractice Insurance carrier (if applicable):

Effective Date:

Expiration Date:

  I am currently a Kansas Locum Tenens provider

  I agree to complete at least four temporary coverage assignments with the Kansas Locum Tenens program within one year if selected to receive malpractice insurance sponsorship.

Please type your full name below for an electronic signature if you have read and agree to the terms stated in the Policies and Procedures.

I am/or have: (check all that apply)

   OMS Recipient
   KMSL Recipient
  NHSC Recipient
  Participated in a Rural Medicine Interest Group
  Kansas Recruitment and Retention Center participant
   From are rural Kansas community   
   Rural Health Scholar
   Kansas Bridging Plan Recipient
   Entered into employment agreement with
   Completed a rural elective
   Provided temporary coverage services outside of KLT
   None of the above


How did you hear about Kansas Locum Tenens? Please be specific.

     

Last modified: Aug 05, 2013
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