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APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS (U.S. Department of Veterans Affairs)

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VA FORM
JUN 2016 (R)
10-2850
Approved Exception To SF 171
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
Affairs to determine your eligibility for appointment in Veterans Health Administration. INSTRUCTIONS: Please submit this
application furnishing all information in sufficient detail to enable the Department of Veterans Type, or print in ink. If additional
space is required, please attach a separate sheet and refer to items being answered by number.
1. NAME (Last, First, Middle) (Mandatory)
3. PRESENT ADDRESS (Street Address 1) STREET ADDRESS 2 APT. NO.
4. TELEPHONE NUMBER (Include Area Code)
CITY STATE ZIP CODE COUNTRY
4A. RESIDENCE 4B. BUSINESS
5. DATE OF BIRTH 6. PLACE OF BIRTH (City) STATE COUNTRY 7. SOCIAL SECURITY NUMBER (Mandatory)
8A. CITIZENSHIP
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN NOT A U.S. CITIZEN (Complete item 8B)
2. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify below)
8B. COUNTRY OF WHICH YOU ARE A CITIZEN
9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
YES (If "YES", complete items 9B and 9C) NO
10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
9B. NAME OF OFFICE WHERE FILED 9C. DATE FILED
11. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
12A. DATE FROM 12B. DATE TO
12E. TYPE OF DISCHARGE
HONORABLE
12C. SERIAL OR SERVICE NO. 12D. BRANCH OF SERVICE
OTHER (Explain on separate sheet)
II - LICENSURE, DEA/STATE CERTIFICATION, SPECIALTY BOARDS AND CLINICAL PRIVILEGES
13A. LIST ALL STATES/TERRITORIES/COMMONWEALTHS OF THE U. S.
OR THE DISTRICT OF COLUMBIA, WHERE YOU ARE OR HAVE EVER
BEEN LICENSED (If not held now, explain on a separate sheet)
14. DO YOU HAVE PENDING, OR HAVE YOU
EVER HAD ANY LICENSE REVOKED
SUSPENDED, DENIED, RESTRICTED, LIMITED
OR ISSUED/PLACED IN A PROBATIONAL
STATUS OR VOLUNTARILY RELINQUISHED
15A. NUMBER OF CURRENT OR MOST
RECENT DEA (DRUG ENFORCEMENT
ADMINISTRATION) CERTIFICATE AND/OR
STATE LICENSE/PERMIT TO PRESCRIBE
CONTROLLED SUBSTANCES
15B. DATE OF
EXPIRATION
YES (If "YES", explain on separate sheet)
NO
16A. ARE YOU CERTIFIED BY AN AMERICAN
SPECIALTY BOARD (General Certification)
YES (If "YES", provide names of boards below)
NO
13B. LICENSE NO.
16B. DATE
13C. CURRENT REGISTRATION (If
"NO" explain on separate sheet)
YES
NO NOT REQUIRED
13D. EXPIRATION
DATE
15C. HAVE YOU EVER HAD A DEA
CERTIFICATE OR STATE LICENSE/PERMIT
REVOKED, SUSPENDED, LIMITED,
RESTRICTED IN ANY WAY OR
VOLUNTARILY RELINQUISHED
YES (If "YES", explain on separate sheet)
NO
16C. SPECIAL CERTIFICATIONS (Recognized
by American Board after exam)
16D. DATE
YES (If "YES", provide names of boards below)
NO
16E. LIST AND PROVIDE DETAILS OF ALL CERTIFICATIONS BY OTHER THAN AN AMERICAN SPECIALTY BOARD (Use separate sheet if more space is necessary)
17A. DO YOU CURRENTLY HAVE OR HAVE
YOU EVER HAD CLINICAL PRIVILEGES AT
ANY HEALTH CARE INSTITUTION OR
AGENCY
YES (If "YES", complete item 17B) NO
17B. NAME AND ADDRESS OF CURRENT OR MOST RECENT
INSTITUTION, AGENCY OR ORGANIZATION WHERE HELD
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
REVOKED, SUSPENDED, REDUCED, LIMITED, NOT
RENEWED, OR VOLUNTARILY RELINQUISHED
YES (If "YES", explain on separate sheet) NO
III - THIS SECTION TO BE COMPLETED BY THE CHIEF OF STAFF
I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of
citizenship. Board certification has been verified (if appropriate).
CERTIFICATION:
18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO: 19A. SIGNATURE OF CHIEF OF STAFF 19B. DATE
BOARD
CERTIFICATION
CURRENT
REGISTRATION
(All States)
FULL
LICENSURE
NATURALIZED
CITIZENSHIP
VISA
PAGE 1
EXISTING STOCK OF VA FORM 10-2850, JUN 2006, WILL BE USED.
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VA FORM
JUN 2016 (R)
10-2850
IV - PROFESSIONAL LIABILITY INSURANCE
20A. PRESENT PROFESSIONAL
LIABILITY INSURANCE CARRIER
21. HAS ANY CARRIER EVER CANCELLED,
DENIED OR REFUSED TO RENEW YOUR
INSURANCE
20C. NAMES OF PRIOR
CARRIERS
20D. DATES OF COVERAGE
20B. DATE
COVERAGE BEGAN
FROM TO
(If "YES", explain on
separate sheet)
YES
NO
V - PREPROFESSIONAL EDUCATION
22C. SUBJECT
MAJOR
22D. YEARS
ATTENDED
22E. GRADUATED
22F.
DEGREE
22A. NAME OF SCHOOL 22B. ADDRESS (City, State and ZIP Code)
MONTH YEAR
VI - PROFESSIONAL EDUCATION
23D. GRADUATED
23C. YEARS
ATTENDED
23E.
DEGREE
23A. NAME OF SCHOOL 23B. ADDRESS (City, State and ZIP Code)
MONTH YEAR
NOTE: For items 24 through 27, identify service as a paid Federal employee including service with VA, U.S. Military or Public Health Service. Include
and identify internship or general practice residencies. DO NOT include externships.
Vll - RESIDENCY TRAINING AND FELLOWSHIPS SUBSEQUENT TO GRADUATION FROM PROFESSIONAL SCHOOL
24F.
NO. OF
MONTHS
24B. ADDRESS (City, State and ZIP Code)
24C.
SPECIALTY
24E. COMPLETED
24A. NAME OF HOSPITAL
OR INSTITUTION
24D. PG
LEVEL
MONTH YEAR
VIII - TEACHING AND/OR RESEARCH ASSOCIATIONS AND APPOINTMENTS WITH PROFESSIONAL SCHOOLS
25A. INSTITUTION 25B. ADDRESS (City, State and ZIP Code) 25C. POSITION 25D. DATE FROM 25E. DATE TO
IX - VISITING STAFF HOSPITAL APPOINTMENTS
26A. INSTITUTION 26B. ADDRESS (City, State and ZIP Code) 26C. POSITION 26D. DATE FROM
26E. DATE TO
X - PROFESSIONAL EXPERIENCE
27E.
PART-TIME
AVERAGE
HOURS
PER WEEK
27C. POSITION (Where
applicable, also specify
whether General
practitioner or Specialist)
27F. DATES EMPLOYED
27D.
FULL
TIME
27A. EMPLOYER 27B. ADDRESS (City, State and ZIP Code)
FROM TO
XI - GENERAL INFORMATION
28. NAMES UNDER WHICH YOU WERE EMPLOYED IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
PAGE 2
VA FORM
JUN 2016 (R)
10-2850
29. LIST ALL PROFESSIONAL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS AND FELLOWSHIPS (If
additional space is required, attach separate sheet)
30. REFERENCES: List four persons, preferably in your specialty, living in the United States who are not related to you by blood or marriage and who
have been in a position to judge your professional qualifications during the past five years.
30A. NAME 30B. ADDRESS (Street, City, State and ZIP Code) 30C. AREA CODE/PHONE NO.
ITEM NO.
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER
30D. BUSINESS OR OCCUPATION
31.
32.
33.
Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based
upon military, Federal civilian, or District of Columbia service?
Does the Department of Veterans Affairs (VA) employ any relative of yours (by blood or marriage)? If "YES", give
separately such relative's (1) full name; (2) relationship; (3) VA position and employment location.
ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL OR JUDICIAL
PROCEEDINGS IN WHICH MALPRACTICE ON YOUR PART IS OR WAS ALLEGED? (If "YES" give details including
name of action or proceedings, date filed, court or reviewing agency, and the status or disposition of case concerning
allegations, together with your explanation of the circumstances involved.)
(As a provider of health care services, VA has an obligation to exercise reasonable care in determining that applicants are
properly qualified. It is recognized that many allegations of professional malpractice are proven groundless. Any conclusion
concerning your answer as it relates to professional qualifications will be made only after a full evaluation of the
circumstances involved.)
YES NO
NOTE: A conviction or a discharge does not necessarily mean you cannot be appointed. The nature of the conviction or discharge and how long ago it
occurred is important. Give all the facts so that a decision can be made. If your answer to question 36, 37 or 38 is "YES" give for each offense: (1) date;
(2) charge; (3) place; (4) court and (5) action taken. When answering item 36 or 37, you may omit (1) traffic fines for which you paid a fine of $100.00
or less; (2) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law; (3) any
conviction the record of which has been expunged under Federal or State law; and (4) any conviction set aside under the Federal Youth Corrections Act
or similar State authority.
34.
35.
36.
37.
38.
39.
40.
Within the last five years have you been discharged from any position for any reason?
Within the last five years have you resigned or retired from a position after being notified you would be disciplined or
discharged, or after questions about your clinical competence were raised?
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives
offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but
does not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment
of two years or less.)
During the past seven years have you been convicted, imprisoned, on probation or parole, or forfeited collateral, or are you
now under charges for any offense against the law not included in 36 above?
While in the military service were you ever convicted by a general court-martial?
If you were in the military service as a physician, dentist, podiatrist, optometrist, or chiropractor, did you ever receive a
non-judicial punishment (Article 15)?
Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits,
and other debts to the U.S. Government, plus defaults on any Federally guaranteed or insured loans such as student and home
mortgage loans.)
If “Yes”, explain on a separate sheet the type, length, and amount of the delinquency or default and steps you are taking to
correct errors or repay the debt. Give any identification numbers associated with the debt and the address of the Federal
agency involved.
XII - SIGNATURE OF APPLICANT
NOTE: A false statement on any part of your application may be grounds for not hiring you, or for terminating you after you begin work.
Also, you may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY
STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
CERTIFICATION:
41A. SIGNATURE OF APPLICANT 41B. DATE (Month, Day,Year)
PAGE 3
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VA FORM
JUN 2016 (R)
10-2850
AUTHORIZATION FOR RELEASE OF INFORMATION
In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and suitability for
employment, I:
Authorize VA to make inquiries concerning such information about me to my previous employer(s), current employer, educational
institutions, State licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association,
Federation of State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as
references, and to any other appropriate sources to whom VA may be referred by those contacted or deemed appropriate;
Authorize release of such information and copies of related records and/or documents to VA officials;
Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries; and
Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable
VA to make such inquiries.
DATE
SIGNATURE
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of
section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average
30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
AUTHORITY: The information requested on the attached application form and Authorization for Release of Information is solicited under Title 38,
United States Code, Chapters 73 and 74.
PURPOSES AND USES: The information requested on the application is collected primarily to determine your qualifications and suitability for
employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel
administration processes carried out in accordance with established regulations and the published notice of the system of records "Applicants for
Employment under Title 38, U.S.C.-VA" (02VA135)
ROUTINE USES: Information on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or
local agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards,
and/or appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically
verify, evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon
proper request, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may also be
released without your prior consent to Federal agencies, State licensing boards, or similar boards or entities, in connection with the VA's reporting of
information concerning your separation or resignation as a professional staff member under circumstances which raise serious concerns about your
professional competence. Information concerning payments related to malpractice claims and adverse actions which affect clinical privileges also may
be released to State licensing boards and the National Practitioner Data Bank. The information you supply may be verified through a computer matching
program at any time.
EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is
voluntary; however, failure to provide this information may delay or make impossible the proper application of Civil Service rules and regulations and
VA personnel policies and thus may prevent you from obtaining employment, employees benefits, or other entitlements.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the
SSN is authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal
career from the time of application through retirement. It will be used primarily to identify your records. The SSN also will be used by Federal agencies
in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations.
The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance
with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in
statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal
employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
PAGE 4
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APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS (U.S. Department of Veterans Affairs)

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