HOSPITAL FORM - PHYSICIAN
Access this form via website at: cca.hawaii.gov/pvl
TO THE APPLICANT: Complete the "Applicant" section of this form. Send a form to each hospital where you have held, or applied for, privileges,
consultation, teaching appointments or locum tenens positions or served in an internship or residency during any part of the most recent
3 years preceding your application for a physician's license in Hawaii. Your residency program director may complete this form in place
of each hospital's administrator. If more than one form is needed, please duplicate both pages.
APPLICANT
Name (First, Middle) (Last) Social Security No.: Birthdate:
Date Served/Applied: Capacity Served or Applied for: Name of Hospital/Residency Program
To: CHIEF OF STAFF, ADMINISTRATOR OF HOSPITAL OR RESIDENCY PROGRAM DIRECTOR
I am applying for a license to practice medicine and surgery in Hawaii. The Board requires this form be completed by the Chief of
Staff or Administrator in each hospital where I have held, or applied for, privileges, consultation, teaching appointments or locum tenens
positions or served in an internship or residency. For my residency program, the program director may complete this form. This request
relates to a background investigation that must be completed prior to my being considered for a Hawaii license.
This is your authority to release any information, files, or records, favorable or otherwise, requested by the Hawaii Medical Board
in connection with my application. Please complete the following questionnaire, SUPPLY COPIES OF INFORMATION IN YOUR RECORDS
that would provide further information and return the material directly to the address on the following page.
Signature of Applicant Date
CHIEF OF STAFF or ADMINISTRATOR OF HOSPITAL
NOTE: This form will be used to evaluate the current and past conduct and competency of the applicant. Any adverse/
derogatory information reported may, out of necessity, be shared with the applicant so that the applicant may respond
to that information.
PLEASE COMPLETE SECTIONS "A" AND "C" or "B" AND "C" AS APPLICABLE
A. POSTGRADUATE TRAINING:
1. Is the applicant or has the applicant been engaged in postgraduate training in the program? . . . . . . . . . . . . . . . . YES NO
2. Briefly evaluate the applicant's competence, conduct and professionalism during his/her affiliation.
3.
Has the applicant ever been subject to adverse or disciplinary actions (e.g. any remediation, restriction,
removal from patient care, probation, suspension, termination, extra training requirement, etc.)? . . . . . . . . . . .
YES NO
4. Is any disciplinary or adverse action pending against the applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
(CONTINUED ON PAGE 2)
MD-08 1215R
In the event the response to any of the questions numbered A.3. through A.7. is "YES", please file a typewritten or legible
handwritten detailed explanation and provide copies of records from your files.
5. Is the applicant presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Has the applicant withdrawn or resigned (voluntary or otherwise) from the program? . . . . . . . . . . . . . . . . . . . . . . .6.
7. Has the applicant been issued a notice of contract termination, non-renewal or non-promotion? . . . . . . . . . . . .
YES NO
YES NO
YES NO
B. HOSPITAL PRIVILEGES:
1. Were privileges extended to the applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In the event the response to any of the questions numbered B.2. through B.6. is "YES", please file a typewritten or legible
handwritten detailed explanation and provide copies of records from your files.
YES NO
Please describe the types of privileges:
If "NO", please explain:
