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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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