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APPLICATION TO SERVE AS A CONSULTANT TO THE COLORADO MEDICAL BOARD PLEASE NOTE: All applicants for Consultant positions must be licensed, must have practiced in Colorado for at least five years, and must not have been subject to professional discipline. IDENTIFYING INFORMATION Name in Full Last
First
Middle
Colorado License Number and Original Issue Date: Physician-MD __________ Physician-DO__________ Physician Assistant__________ Anesthesiologist Assistant________ Specialty
____________________________________________________________________
Office Address: Street
City
State
Zip
Phone
Street
City
State
Zip
Phone
Residence Address: Date of Birth: EDUCATIONAL LEVEL List University and Postgraduate Only NAME OF SCHOOL
DATE CITY
STATE
FROM
TO
DEGREE EARNED
INTERNSHIPS, RESIDENCIES OR FELLOWSHIPS (List all hospitals or facilities where you received post-graduate training) NAME OF SCHOOL
DATE CITY
STATE
FROM
TO
BOARD CERTIFICATION Are you eligible to take, or have you taken the certification exam in your specialty? YES Date Eligibility Ends: Certified By:
Date:
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NO
DEGREE EARNED
APPLICATION TO SERVE AS A CONSULTANT TO THE COLORADO MEDICAL BOARD MEMBERSHIPS ON HOSPITAL STAFFS Dates Name
City
State
From
To
MEMBERSHIPS AND OFFICES HELD IN PROFESSIONAL SOCIETIES Dates Organization
Position Held
From
To
PLEASE LIST ALL AREAS IN WHICH YOU ARE QUALIFIED TO OFFER EXPERT OPINION
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you have expertise as a Medical Director? If so, what type of practice____________________________________ Do you supervise physician assistants? ______________Do you supervise an anesthesiologist assistants? __________ Do you supervise residents? ________________
PROFESSIONAL PUBLICATIONS AND HONORS
LICENSE INFORMATION List OTHER states in which you have a professional license: State
Number
State
Number
State
Number
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APPLICATION TO SERVE AS A CONSULTANT TO THE COLORADO MEDICAL BOARD Please answer the following questions by checking the correct box: 1. Has any license entitling you to practice medicine as a physician assistant or anesthesiologist assistant, in any jurisdiction, been refused, suspended, revoked, placed on probation, or received sanctions or any other discipline? YES NO 2.
Have you ever been disciplined, suspended, had your privileges limited, been put on probation, or been removed involuntarily from a hospital or any institution’s dental staff? YES NO
3. Has your DEA Certificate ever been refused, suspended, revoked, or placed on probation? 4. Have you ever been convicted of a felony? 5.
YES
NO
YES
NO
Have you ever had malpractice or liability insurance coverage suspended, or renewal refused or denied? YES
NO
6.
Are there any malpractice judgments entered against you in any state or federal court, or have you agreed to any out-of-court settlements of malpractice claims? YES NO
8.
Have you been engaged as an expert witness before?
9.
Have you testified in a civil case before?
YES
NO
YES
NO
10. Have you participated as a witness or as a party in a malpractice case?
YES
NO
11. Do you provide IME’s (independent medical evaluations)?
YES
NO
If “YES”, please indicate for whom and how many per year. If you have answered “YES” to any of the above questions, please explain below: (Use the back of this sheet if necessary):
Return to: Colorado Medical Board 1560 Broadway, Suite 1350 Denver, CO 80202
Please attach your Curriculum Vitae to this application.
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