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:

 

Comments:

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

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
Questions?
Do you have any questions? Check out our KLT FAQs. For more information about "Becoming a Provider" or "Requesting Service" contact Andrea Ellis at 913-588-1228 or aellis2@kumc.edu.
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