Applicant completes an application that includes, reasons for inability to perform, las of present illegal

drug use, loss of license or felony convictions. Loss or limitation of privileges or disciplinary actions.

Current malpractice insurance coverage, current signed attestation confirming the correctness and

completeness of the application. If an application from an external entity is used it must include the

questions and attestations as identified above. Signature stamps are not acceptab...
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