Applicant Name: [text-296] address: [text-992] Foreign address: [text-264] Country: [text text-264] Date of Birth: [date-506] Place of birth: [text-195] Are you a U.S. citizen?: [text text-911] Date of entry into the U.S.: [date-190] Visa/Passport Number: [text-781] Medical Student: [radio-522] Externship Physicians: [radio-628] Medical School attending:[text-808] Address: [text-808] Dates Attended: [date-306] year of graduation:[date-306] additional medical training:[text-808] Provide the duration of your additional medical program FROM: [date-663] TO: [date-664] title of the person(s) who will be supervising your additional medical program: [text-808] Will you provide direct patient care: [radio-628] if No, are your activities limited to observation only?
4. Has (have) any judgment(s), settlement(s), payment(s), claim(s), suit(s) or demand(s) been made against you, such as would fall under the proposed insurance? : [radio-222] If Yes, provide details: [text-356] Are you aware of any fact, circumstance or situation which might afford grounds for any claim, such as would fall under the proposed insurance?: [radio-212] If Yes, provide details: [text-356] 6. Has any insurer declined, canceled or non-renewed any Medical Professional Liability Insurance Policy or any similar insurance on your behalf? : [radio-211] If Yes, provide details :[text-954] Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule?: [radio-311] HIPAA Privacy Rule?: [radio-411] Applicant’s Privacy Officer:[text-954] Upload Resume [file-387] Signature of Applicant: [text-264] Date [date-506]


This e-mail was sent from a contact form on AICGC (https://www.aicgc.org)