Resident Profile Form

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

Residency program:

Date of Completion:

Program level:

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

Telephone (office):

Telephone (home):

Kansas License number:

Date issued:

Date expires:

Malpractice Insurance carrier :

Effective Date:

Expiration Date:

DEA Certificate Number:

DEA Expiration Date:

Time periods available for Locum Tenens:


Time periods not available for Locum Tenens:


List procedures performed:


List practice limitations:



Preferred e-mail address:
(please be specific, i.e:

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

To submit, please press

To clear the form and start over, please press

Last modified: Jul 29, 2013

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For more information about how to "Become a Provider" or "Request Coverage" contact Andrea Ellis at 913-588-1228 or

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Register as a KLT Provider