SCI Provider Application

PERSONAL INFORMATION

Address
Birthdate
Have you ever spoken with a member of our team before?
 

EDUCATION INFORMATION

 

LICENSURE

Do you have an active DEA license?
Are you board certified?
Do you carry your own malpractice insurance?
 

CERTIFICATIONS

BLS
PALS
OTHER
ACLS
NALS
 

REFERENCES

Reference 1

Reference 2

Reference 3

 

JOB PREFERENCES

 

ATTESTATION QUESTIONS

If you answer yes to any of the following, please provide an explanation, along with any necessary supporting documents. Please use the File Upload feature at end of form to upload any supporting documents.
Do you have any physical conditions that may limit or hinder your performance in the position for you are applying?
Have you ever been convicted of a felony, misdemeanor, or crime other than a traffic violation?
Have your privileges at any healthcare facility ever been voluntarily or involuntarily relinquished, denied, or suspended?
Have you ever been the subject of disciplinary proceedings at any healthcare facility?
Has your license or certification in any state ever been voluntarily or involuntarily relinquished, suspended, or terminated?
Have you ever been the subject of disciplinary proceedings or investigation by any state licensure board?
Have you ever been suspended, terminated, sanctioned, or otherwise restricted from any health insurance program?
Have you ever been named in, or had any past/pending judgments made against you in a professional malpractice liability case?
 

DOCUMENTS & FILES

Please upload a document or zipped folder containing your CV or resume, and additional supporting documents requested by your recruiter or SCI Credentialing Department. Total files uploaded must be less than 5MB, allowed file types are zip, pdf, doc, docx, rtf, jpg.
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
 
STATEMENT OF AUTHORIZATION & RELEASE
I certify that my answers are true and complete. If this application leads to employment, I understand that false or misleading information in my application may result in my dismissal. SCI Anesthesia Services, and its representatives are hereby authorized to make any investigations of my personal and professional history through any agency or bureau necessary, including verification background checks, E-verify, degree verifications, insurance claims history requests, loss run requests, and transcript requests from my educational institutions. SCI Anesthesia Services is also authorized to investigate my ability, employment records or character through inquires to individuals and/or employers mentioned in this application. I hereby agree that this authorization and appointment shall be valid until revoked by me in written revocation delivered to SCI Anesthesia Services. I hereby release SCI Anesthesia Services and the person(s) to whom the inquiry is made from any and all claims and liability growing out of such inquiries, and consent to the release of such information.

SCI Healthcare

Founded in 2022, SCI Healthcare is a recruiting firm that provides professional staffing services to organizations throughout the United States. Our client base includes facilities ranging from large to small hospitals, national and regional management groups, and outpatient facilities.