ADD/CHANGE OF PRIMARY SUPERVISING MD

PLEASE CLICK HERE FOR ADD/CHANGE INFORMATION AND CHECKLIST DOCUMENT

Here is where you submit your application and supporting documents:

Our Email: [email protected]

APPLICATIONS WILL NOT BE REVIEWED WITHOUT APPLICATION FEE OF $75.00

AVAILABLE FORMS TO DOWNLOAD (YOU MAY NOT NEED ALL OF THESE, PLEASE REFER TO CHECKLIST)

ADD OR CHANGE SUPERVISING PHYSICIAN FORM

FORM B - REQUEST FOR ADDITIONAL DUTIES

FORM E - ANESTHESIA JOB DESCRIPTION

FORM F - PRIMARY CARE JOB DESCRIPTION

FORM H - SEPARATION NOTIFICATION

FORM J - Specific Power of Attorney

Utilization Form