Application for Clinical Staff
Zufall Health Center is an equal opportunity employer and will not discriminate on the basis of race,
creed, religion, color, national origin, ancestry, age, sex, sexual orientation, marital status, atypical
heredity, cellular or blood trait, disability (including AIDS and HIV infection) and liability for service
in the United States armed forces or any other legally protected status.
Today’s Date ______________
Date you can start___________________
First Name _______________________ Middle Initial ________ Last Name ____________________
Street Address ______________________________________________________________________
City _____________________ State _______ ZIP _______ County _______________
Telephone (
) ______ - __________ (Home)
Telephone (
) ______ - __________ (Cell)
E-mail Address: _____________________@______________________
Volunteering for: __________________________ Full-time Part-time  Flexible
Position (Paid)
__________________________ Full-time Part-time
Salary Request: $_____________________
Per-Diem Flexible
Hourly Annually
What days/hours are you available? _____________________________________________________
Are you willing to work:
Specialty:
Weekends?  Yes  No
Evenings?  Yes  No
Medical
Pediatrics
Podiatry
Obstetrics & Gynecology
Dentistry
Mental Health
Other (Indicate) ____________________________
Are you either a U.S. citizen or a legal alien who has the right to remain permanently and work in the
U.S?  Yes  No (Proof of citizenship or immigration status will be required upon employment)
Please indicate names of friends and/or relatives who are employed at ZHC:
___________________________________________________________________________________________________
May we contact you at work?  Yes  No
How did you hear of this opening? ______________________________________________________
Have you ever applied for employment here?  Yes  No
When? ___________________________________ Where?__________________________________
Have you ever been employed by Zufall Health Center?  Yes  No
When? ___________________________________ Where?__________________________________
Are you presently employed?  Yes  No May we contact your present employer?  Yes  No
Will you relocate?  Yes  No
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Are you willing to travel?  Yes  No If yes, what percent? __________________________
 Education
School Name/ Location
(Complete Address)
Years Attended
mm/yy – mm/yy
Subjects/Specialties
Major/Minor
Degree Awarded
**Former Name on Degree
Undergraduate
College
Graduate
School/College
Pre-Medical
Medical/Dental
School
Other Education
 Internships, Residencies/Fellowships/Preceptorships
Dates
Month/Year
Intuition Name Address,
City, State, Zip.
Program Director’s
Name & Phone
Specialty
Type of Training
Languages spoken other than English: _________________________________________________
In addition to your work history, are there are other skills, qualifications, or experience that we should
consider?
______________________________________________________________________________
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 Employment History
Date
Month/Year
(Start with most recent employer)
Employer Name
Address/ Telephone
Job Title
Supervisor’s Name
Current or
Final Salary
Reason for Leaving
Resume attached (Please complete application entirely)
 References
List three professional references that can attest to the quality of your work.
Name
Relationship
Address (Street/City/State)
Telephone Number w/area code
Name
Relationship
Address (Street/City/State)
Telephone Number w/area code
Name
Relationship
Address (Street/City/State)
Telephone Number w/area code
 Hospital Affiliations
Date
Month/Year
Institution Name
(Address City, State, Zip)
Dept. Chief’s
Name/Telephone
Specialty
Reason for Leaving
From:
To:
From:
To:
From:
To:
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 Licenses
Date Issued:
Date Expires:
MEDICARE Number
#
National Provider ID (NPI)
#
New Jersey License Number
NJ Narcotics Registration No.
(CDS)
Federal Narcotics Registration
No. (DEA)
Other State’s License (Indicate
state name and license no.)
Other State’s License (Indicate
State name and license no.)
E.C.F.M.G. Certification No.
(or equivalent)
List Other Certifications such as
BLS, ACLS, FALS, ATLS
MEDICAID Number
#
 HMO Affiliations
Group Name
Provider Name
Date Issued
Date Expires
 Board Certifications
Name of Board
Date Certified
Date Expires
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 Professional Memberships
Diplomat
College
Dates
If you respond “Yes” to any of the questions below, please provide an explanation on a separate sheet
of paper. If question does not apply, please write in “N/A.”
Licensure
1. Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted,
voluntarily surrendered while under investigation or have you ever been subject to a consent order,
probation or any conditions or limitations by any state licensing board?
 Yes  No
2. Has your federal or state narcotics license ever been suspended, limited, revoked, voluntarily
suspended or not renewed, or has probation ever been invoked?
 Yes  No
3. Have you ever received a reprimand or been fined by any state licensing board?
 Yes  No
Hospital Privileges and Other Affiliations
4. Have your clinical privileges at any hospital or healthcare institution ever been denied, suspended,
revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions
(for reasons other than non-completion of medical records when quality of care was not adversely
affected) or have proceedings toward any of those ends been instituted or recommended by any
hospital or healthcare institution, medical staff or committee, or governing board?  Yes  No
5. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while
under investigation?
 Yes  No
6. Have you ever been terminated for cause or not renewed for cause from participation, or been
subject to any disciplinary action, by any managed care organizations (including HMO’s PPOs, or
provider organizations such as IPAs or PHOs)?
 Yes  No
Education, Training and Board Certifications
7. Have you ever been placed on probation, disciplined, formally reprimanded, suspended or asked to
resign during an internship, fellowship, preceptorship or other clinical education program?
 Yes  No
8. If you are currently in a training program, have you been placed on probation, disciplined, formally
reprimanded, suspended or asked to resign during an internship, residency, fellowship,
preceptorship or other clinical education program?
 Yes  No
9. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your
status as a student or employee in any internship, residency, fellowship, preceptorship, or other
clinical education program?
 Yes  No
10. Have any of your board certifications or eligibility ever been revoked?
 Yes  No
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11. Have you ever chosen not to re-certify or voluntarily suspended your board certification(s) while
under investigation?
 Yes  No
DEA or CDS Certification/Authorization
12. Have your Federal and /or State Controlled Dangerous Substances (CDS) certificate(s) or
authorization(s) ever been denied, suspended, and revoked, restricted, denied renewal, or
voluntarily relinquished?
 Yes  No
Medicare, Medicaid and Other Governmental Program Participation
13. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned,
censured, disqualified, or otherwise restricted in regard to participation in the Medicare or
Medicaid program, or any other private, federal or state health program?
 Yes  No
Other Sanctions or Investigations
14. Are you currently or have you ever been the subject of an investigation by any hospital, licensing
authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid
program, or any other private, federal or state health program?
 Yes  No
15. To your knowledge, has information pertaining to you ever been reported to the National
Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?
 Yes  No
16. Have you ever received sanctions from or been the subject of investigation by any regulatory
agencies (e.g., CLIA, OSHA, etc.)?
 Yes  No
17. Has a patient, employee, or co-worker ever accused you of sexual harassment or other illegal
misconduct that resulted in an investigation, sanction or other formal action?
 Yes  No
18. During your military career, if applicable, have you ever been investigated, sanctioned,
reprimanded or cautioned by a military hospital, facility, or agency, voluntarily terminated pr
resigned while under investigation by a hospital/healthcare facility of any military agency?
 Yes No
19. Have you ever been court-martialed for actions related to your duties as a medical professional?
 Yes
 No
Professional Liability Insurance Information
20. Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by
the carrier based on your individual liability history?
 Yes  No
21. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your
professional liability insurance carrier, based on your individual liability history?  Yes  No
Malpractice Claims History
22. Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated,
medicated or litigated)? If yes, please provide information for each case ( list each action
separately)
 Yes  No

Date of Occurrence

Claim/case status

Date claim was filed
Page 6 of 12

Professional liability insurance carrier involved(include name, address, phone number and
policy number)

Amount of award or settlement and amount paid:

Method of Resolution
 Dismissed
 Judgment for plaintiff(s)
 Mediation/Arbitration
 Settled (with prejudice)
 Judgment for defendant(s)
 Settled (without prejudice)

Description of allegations

Indicate whether you were primary defendant or co-defendant

Number of other co-defendants

Indicate your involvement in the case (attending, consulting, etc.)

Description of alleged injury to the patient
Criminal/Civil History (Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be based
upon all relevant circumstances, including the nature of the crime.)
23. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony in the last
ten years or been found liable or responsible for or named as a defendant in any civil offense that is
reasonably related to your qualifications, competence, functions, or duties as a medical
professional?............................................................................................................  Yes  No
24. Have you ever been convicted of, pled guilty or pled nolo contendere to any felony in the last ten years
or been found liable or responsible for or been named as a defendant in any civil offense that alleged
fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?........  Yes  No
25. Have you ever been indicted in any civil or criminal suit?.............................................  Yes  No
26. Are you currently engaged in the illegal use of drugs? (“Currently” means sufficiently recent to justify
a reasonable belief that the use of drugs may have an ongoing impact on one’s ability to practice
medicine. “Illegal use of drugs” refers to drugs whose possession or distribution is unlawful under the
Controlled Substances Act, 21 U.S.C. section 812.22. It “does not include the use of a drug taken
under supervision by a licensed health care professional, or other uses authorized by the Controlled
Substances Act or other provision of Federal law” The term does include, however, the unlawful use of
prescription controlled substances.…………… Yes  No
27. Do you use any chemical substances that would in any way impair or limit your ability to practice
medicine and perform the functions of your job with reasonable skill and
safety:…………………………………………………………………………………… Yes  No
28. Do you have any reason to believe that you would pose a risk to the safety or well being of your
patients? …………………………………………………………………………………… Yes  No
29. Do you have Professional Liability (Malpractice) Insurance coverage in force? ………… Yes  No
(If “No” please explain.)
Are you able to perform the essential functions of a practitioner in your area of practice with or without
reasonable accommodation? …………………………………………………………… Yes  No
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REQUEST FOR CLINICAL PRIVILEGES
I, __________________________________,request clinical privileges in the following (circled) and at the
following (checked) Zufall Health Center sites:
Dover – 18 W Blackwell Street
Morristown
Highlands Health Van
Somerville
1.
2.
3.
4.
5.
6.
Dover – 17 S Warren Street (Dental)
Hackettstown
Flemington
West Orange
Pediatrics
a. Evaluation and treatment of medical conditions in patients 0 to 18 years of age, including performance of
appropriate history and physical exams, performance and ordering of diagnostic studies, prescription and
dispensing of medications, providing anticipatory guidance, and counseling regarding safety and lifestyle.
b. Well child evaluations
c. Immunizations
d. Office minor surgical procedures, including I & D, repair of lacerations, and removal of foreign bodies.
Adult Medicine
a. Evaluation and treatment of medical conditions in adult patients, including performance of appropriate
history and physical exams, performance and ordering of diagnostic studies, prescription and dispensing
of medications and counseling regarding safety and lifestyle.
b. Immunizations
c. Office minor surgical procedures including I & D’s, repair of lacerations, excision of skin and
subcutaneous lesions, and removal of foreign bodies.
Dental
a. Evaluation and treatment of general dentistry patients, including appropriate general dentistry office
procedures, prescription and or dispensing of medications, and recommending subspecialty referrals
when indicated.
Podiatry
a. Diagnosis and treatment of ailments of the human foot and ankle by any one or more of the following:
local medical (construed to mean the prescription or use of a therapeutic agent or remedy where the
action or reaction is intended for a localized area), mechanical, surgical, manipulative and physiotherapeutic.
Pre-natal
a. Evaluation and treatment of prenatal patients including performance of history and physical exams,
performing and ordering diagnostic tests and prescription and dispensing of medications.
b. Referral of patients to other practitioners as indicated.
Women’s Health
a. Evaluation and treatment of adolescent and adult women including performance of
appropriate
history and physical exams, performance and ordering of diagnostic studies, prescription and dispensing
medications, and counseling regarding safety and lifestyle.
b. Evaluation and treatment for conditions including anemia, abdominal pain, breast problems, PMS,
dysmenorrhea, infertility, cystitis, STD’s, hormonal therapy, non procedural contraception, menstrual
irregularities, vaginal infections, lesions of lower genital tract, screening for gyn oncology, pregnancy
testing, and preconception counseling.
c. Performance of ambulatory procedures such as endometrial biopsy and colposcopy for management of
abnormal conditions, and insertion of intrauterine devices as a means of contraception.
Signature of Provider: _________________________________________ ________________
Date
Renewed and recommended by: _________________________________ ________________
Date
Approved by Board of Directors: ________________________________ ________________
Date
Page 8 of 12
To Whom It May Concern:
I hereby give permission to release to the Zufall Health Center, information regarding my
undergraduate, professional graduate degree, residency and fellowship program, if applicable and to
query the National Practitioner Databank and licensing boards.
Name: (print) __________________________________________ Date of Birth: ______________
Signature: ____________________________________________
Date:_____________________
Page 9 of 12
AUTHORIZATION TO RELEASE INFORMATION
I, ________________________ ________________________
Last Name
First Name
____________________________________________________
Current Address
____________________
Middle Name
_____________________
Dates Lived Here
Addresses for the Past Seven Years: (include street, city, state, zip code)
Dates of Residence:
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
________________
Date of Birth
_____________________________________
Other Names Used (including maiden name)
_______-_______-_______
Social Security Number
________________
Years Used
_____________________________________
Driver's License #
______
State
do hereby authorize verification of all information in my employment application from all sources of
employment, education, motor vehicle, financial history, criminal history, personal character, and
worker's compensation records in accordance with ADA, labor and wage records, etc. or any part
thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether the
said records are public or private, and including those which may be deemed to be privileged or
confidential in nature and I release all persons from liability on account of such disclosures.
Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc for
identification purposes and for the release information which will be considered in determining any
suitability for employment. I certify that I have made true, correct, and complete answers and
statements on my employment application, any supplements to it and in any interview in the
knowledge that they will be relied upon in considering my application for employment. I agree to
provide additional information that may be requested to process my employment application. I
authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish
the above-mentioned information. This authorization is valid during the course of my employment to
the extent permitted by law.
**I hereby do _______do not_________ authorize you to contact my current employer for
Employment and Reference Verifications (This will authorize immediate inquiries to the Human
Resources Department and to any listed supervisors or references in the Employment/Reference
Section of your application.)
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request
the nature and substance of all information in its files on me at the time of my request, including
Page 10 of 12
sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has
previously furnished within the two year period preceding my request.
I understand and agree that any omission, false statement, misleading statement, or answer made by me
on my application or any supplements to it and in any interviews will be sufficient grounds for
rejection of employment and my discharge after employment.
_______________________________ __________________________________ ___________
Printed Name
Applicant Signature
Date
CALIFORNIA, OKLAHOMA, and MINNESOTA RESIDENTS ONLY: If you are a current
California, Oklahoma, or Minnesota resident and would like to request a copy of your Consumer
Report or Investigative Consumer Report, please check the box. This report may include
character and reputation information obtained through personal interviews.
DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY
KIND. LEGAL ADVICE SHOULD BE SOUGHT FROM YOUR ATTORNEY. WE MAKE NO
CLAIMS, PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS,
OR ADEQUACY OF THE INFORMATION CONTAINED HEREIN. WE MAKE NO
WARRANTY THAT THIS FORM IS APPROPRIATE FOR YOUR PARTICULAR NEEDS.
Page 11 of 12
Please Read Before Signing
I agree to protect the confidentiality of Zufall Health Center patients and agency information and
will not release unauthorized information to any source.
I understand that failure to comply with this agreement may result in disciplinary action up to and
including possible termination
I certify that all information provided by me on this application is true and complete to the best of my
knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this
application.
I authorize my previous employers, schools, or persons listed as references to give any information
regarding employment or educational record. I agree that Zufall Health Center (ZHC) and my previous
employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or
employment is terminated because of false statements, omissions, or answers made by myself on this
application. In the event of any employment with ZHC, I will comply with all rules and regulations as
set by the ZHC in any communication distributed to the employees.
In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required
to provide approved documentation to the company that verifies my right to work in the United States
on the first day of employment. I have received from the company a list of the approved documents
that are required.
I understand that any employment by ZHC will be on a 90 day introductory basis.
I agree to take a physical examination prior to working.
I understand that employment at ZHC is “at will,” which means that either I or this company can
terminate the employment relationship at any time, with or without prior notice, and for any reason not
prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read
and understand the above statements.
Signature _______________________________________________ Date_________________
Thank you for completing this application, and for your interest in employment with us. We would
like to assure you that your opportunity for employment with this agency will be based only on your
merit and on no other consideration.
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