New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Verication of Privileges/Afliation/Employment/Appointment Form
License Applicant’s name:_______________________________________________________________________
Hospital/Facility name: _________________________________________________________________________
Hospital/Facility address: _______________________________________________________________________
Street City State Zip Code Country
Telephone number: _____________________________
Include area code
Postion held at your hospital/facility: _______________________________ from ___________ to ____________
Month/Day/Year Month/Day/Year
1. Was this physician placed on probation, suspended or in any way sanctioned/disciplined while at your
facility? Yes No
2. Was this physician granted a leave of absence while employed at your facility? Yes No
3. Were any restrictions placed on this physician’s activities or privileges that were not placed on others
holding similar positions? Yes No
4. Was this physician subject to non-routine monitoring and/or non-routine quality assessment review?
Yes No
5. Was this physician involuntarily removed from a call schedule? Yes No
6. Was this physician the subject of a negative review while at your facility? Yes No
7. Was this physician the subject of an investigation while at your facility? Yes No
8. Were any malpractice actions led naming this physician during his/her period of employment at your
facility? Yes No
9. Did this physician leave your facility in good standing? Yes No
10. Would you recommend this physician for privileges or consider rehiring this physician at your facility?
Yes No
If you answered “Yes” to any one of questions 1-8, please attach an explanation. You may also attach additional
comments or information that the N.J. State Board of Medical Examiners should consider prior to determining
this applicant’s eligibility for licensure. All attachments should be on your facility’s letterhead.
__________________________________________________________ _____________________________
Print Name and Title of Certifying Ofcial Date
__________________________________________________________
Signature of Certifying Ofcial
Please return directly to: State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183
BME-PEA-17
Hospital
Seal
If the hospital does not
have a seal, a letter
attesting to this fact,
on hospital stationary,
must accompany this
certicate.
click to sign
signature
click to edit
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