TemplatesOwl
Homepage ↦ Fill Out Your Va Application Physician Form
Article Structure

The VA Application Physician form is a crucial document for healthcare professionals seeking to join the Veterans Health Administration. This application gathers detailed information to evaluate an applicant's qualifications and eligibility for appointment. It outlines various sections that require personal data such as name, address, and date of birth, as well as professional credentials including licenses, certifications, and work history. Applicants must disclose their citizenship status, military service, and any potential legal or professional issues that could impact their eligibility. The form also includes sections on professional liability insurance and educational background, ensuring a comprehensive overview of an applicant’s qualifications. Completing this form accurately is essential, as any discrepancies can affect the application process and potentially the hiring decision. As such, attention to detail and thoroughness are imperative when filling out this application.

Va Application Physician Example

Use TAB key or Mouse to move between data fields

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)

 

 

2. APPLICATION FOR (Check one)

 

 

 

 

GENERAL PRACTICE

SPECIALTY (Identify below)

 

 

 

 

 

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

 

 

 

8B. COUNTRY OF WHICH YOU ARE A CITIZEN

U.S. CITIZEN BY BIRTH NATURALIZED U.S. CITIZEN NOT A U.S. CITIZEN (Complete item 8B)

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

11. DATE AVAILABLE FOR EMPLOYMENT

9C. DATE FILED

I - ACTIVE MILITARY DUTY

12A. DATE FROM

12B. DATE TO

12C. SERIAL OR SERVICE NO. 12D. BRANCH OF SERVICE 12E. TYPE OF DISCHARGE

HONORABLE 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.

 

13C. CURRENT REGISTRATION (If

13D. EXPIRATION

OR THE DISTRICT OF COLUMBIA, WHERE YOU ARE OR HAVE EVER

13B. LICENSE NO.

"NO" explain on separate sheet)

DATE

BEEN LICENSED (If not held now, explain on a separate sheet)

 

YES NO

NOT REQUIRED

 

14. DO YOU HAVE PENDING, OR HAVE YOU

 

15A. NUMBER OF CURRENT OR MOST

15B. DATE OF

15C. HAVE YOU EVER HAD A DEA

EVER HAD ANY LICENSE REVOKED

 

RECENT DEA (DRUG ENFORCEMENT

EXPIRATION

CERTIFICATE OR STATE LICENSE/PERMIT

SUSPENDED, DENIED, RESTRICTED, LIMITED

 

ADMINISTRATION) CERTIFICATE AND/OR

 

REVOKED, SUSPENDED, LIMITED,

OR ISSUED/PLACED IN A PROBATIONAL

 

STATE LICENSE/PERMIT TO PRESCRIBE

 

RESTRICTED IN ANY WAY OR

STATUS OR VOLUNTARILY RELINQUISHED

 

CONTROLLED SUBSTANCES

 

 

VOLUNTARILY RELINQUISHED

YES (If "YES", explain on separate sheet)

 

 

 

 

YES (If "YES", explain on separate sheet)

NO

 

 

 

 

NO

 

 

 

 

 

 

 

 

16A. ARE YOU CERTIFIED BY AN AMERICAN

 

16B. DATE

16C. SPECIAL CERTIFICATIONS (Recognized

16D. DATE

SPECIALTY BOARD (General Certification)

 

by American Board after exam)

 

 

YES (If "YES", provide names of boards below)

 

YES (If "YES", provide names of boards below)

 

NO

 

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

 

 

 

 

 

CERTIFICATION:

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).

 

 

 

 

 

 

 

 

 

 

18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:

BOARD

19A. SIGNATURE OF CHIEF OF STAFF

19B. DATE

 

 

 

 

 

CURRENT

 

 

 

 

 

 

 

 

FULL

 

NATURALIZED

CERTIFICATION

 

 

 

 

 

 

REGISTRATION

VISA

 

 

 

 

 

 

LICENSURE

(All States)

 

CITIZENSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM

 

 

EXISTING STOCK OF VA FORM 10-2850, JUN 2006, WILL BE USED.

PAGE 1

 

 

JUN 2016 (R) 10-2850

 

 

 

IV - PROFESSIONAL LIABILITY INSURANCE

20A. PRESENT PROFESSIONAL

20B. DATE

20C. NAMES OF PRIOR

20D. DATES OF COVERAGE

21. HAS ANY CARRIER EVER CANCELLED,

LIABILITY INSURANCE CARRIER

COVERAGE BEGAN

CARRIERS

 

 

DENIED OR REFUSED TO RENEW YOUR

FROM

TO

 

 

 

 

 

INSURANCE

 

(If "YES", explain on

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

separate sheet)

V - PREPROFESSIONAL EDUCATION

22A. NAME OF SCHOOL

22B. ADDRESS (City, State and ZIP Code)

22C. SUBJECT

22D. YEARS

22E. GRADUATED

MAJOR

ATTENDED

MONTH

YEAR

 

 

 

 

22F.

DEGREE

VI - PROFESSIONAL EDUCATION

23A. NAME OF SCHOOL

23B. ADDRESS (City, State and ZIP Code)

23C. YEARS

23D. GRADUATED

ATTENDED

MONTH

YEAR

23E.

DEGREE

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

24A. NAME OF HOSPITAL

OR INSTITUTION

24B. ADDRESS (City, State and ZIP Code)

24C.

SPECIALTY

24D. PG

LEVEL

24E. COMPLETED

MONTH YEAR

24F.

NO. OF

MONTHS

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

27A. EMPLOYER

27B. ADDRESS (City, State and ZIP Code)

27C. POSITION (Where applicable, also specify 27D.

whether General FULL practitioner or Specialist)TIME

27E.

PART-TIME

AVERAGE

HOURS

PER WEEK

27F. DATES EMPLOYED

FROM TO

XI - GENERAL INFORMATION

 

 

 

28. NAMES UNDER WHICH YOU WERE EMPLOYED IF DIFFERENT FROM NAME GIVEN IN ITEM 1.

 

 

 

JUN 2016 (R) 10-2850

PAGE 2

VA FORM

 

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. 30D. BUSINESS OR OCCUPATION

ITEM NO.

PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER

YES

NO

31.

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?

 

 

 

 

 

 

 

 

 

32.

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

33.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.)

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.

Within the last five years have you been discharged from any position for any reason?

 

 

35.

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

36.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.)

37.

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?

 

38.

While in the military service were you ever convicted by a general court-martial?

39.

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

40.

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).

CERTIFICATION:

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY

STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.

 

41A. SIGNATURE OF APPLICANT

VA FORM 10-2850

JUN 2016 (R)

41B. DATE (Month, Day,Year)

PAGE 3

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.

SIGNATURE

DATE

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.

VA FORM

10-2850

PAGE 4

JUN 2016 (R)
Get Va Application Physician PDF Form

Form Characteristics

Fact Name Fact Description
Form Purpose This form is used to assess the qualifications and suitability of physicians, dentists, podiatrists, optometrists, and chiropractors for appointment in the Veterans Health Administration.
Estimated Completion Time The estimated time to complete the form is approximately 30 minutes.
Mandatory Information Certain fields, including name and Social Security Number, are mandatory and must be filled out completely.
Application Verification The form requires verification of licensure, professional qualifications, and citizenship status.
Legal Authority This application is governed under Title 38, United States Code, Chapters 73 and 74.
Information Sharing Information may be shared with federal and state agencies to verify suitability for employment without prior consent.

Guidelines on Utilizing Va Application Physician

Completing the VA Application for Physicians, Dentists, Podiatrists, Optometrists, and Chiropractors is a crucial step in seeking employment with the Veterans Health Administration. Having the required information at hand will make this process smoother, ensuring that your application is processed efficiently.

  1. Begin by entering your full name in the appropriate format: Last, First, Middle. This information is mandatory.
  2. Indicate the type of application you are submitting by checking either "General Practice" or specifying a "Specialty." If you choose "Specialty," be ready to identify it further.
  3. Provide your present address. Include not just your street address, but also the city, state, ZIP code, and in some instances, the country. Make sure to fill in any apartment number if applicable.
  4. List your telephone number, including the area code. This should cover both your residence and business phone numbers if available.
  5. Fill in your date of birth and your place of birth with the city, state, and country.
  6. Disclose your Social Security Number, as this is also mandatory.
  7. For citizenship, indicate whether you are a U.S. Citizen by birth, a naturalized citizen, or not a U.S. Citizen (if the latter applies, complete the relevant field).
  8. Answer whether you have ever filed an application for appointment in the VA by selecting "Yes" or "No." If "Yes," provide the necessary details in items 9B and 9C.
  9. Indicate when inquiries can be made of your present employer.
  10. State your date available for employment.
  11. For questions related to military service, fill out the required dates, service number, branch of service, and type of discharge, providing the type (Honorary or Other) as applicable.
  12. In the licensure section, list all the states or territories where you currently have or have ever held a license, including the license number and its expiration date.
  13. Document any pending or prior revocations, suspensions, or other issues with your licenses or permits.
  14. Provide certification details, including board certifications and any special certifications by other organizations.
  15. List your clinical privileges at any health care institutions or agencies, noting any denials or restrictions.
  16. Provide details about your professional liability insurance, including the carrier, dates of coverage, and whether any insurance was denied or not renewed.
  17. Complete the education sections, starting from pre-professional schools through to professional schools, including institutions, addresses, and degrees.
  18. Outline any residency training and fellowships along with any teaching or research positions held at professional schools.
  19. Summarize your professional experience, specifying details about your past employers, positions held, and employment duration.
  20. Address any specific questions about your service under various conditions, including references to erroneous actions that might have impacted your employment record.
  21. Sign and date the application, certifying that all information provided is accurate and complete.
  22. Complete the authorization for the release of information to allow the VA to verify your qualifications and background.

Taking these steps methodically ensures that your application is complete and that you have provided all necessary information for the VA to assess your qualifications. By following the instructions carefully, you can facilitate a smoother review process and move forward in your pursuit of a position within the Veterans Health Administration.

What You Should Know About This Form

What is the VA Application Physician form used for?

The VA Application Physician form is designed to help the Department of Veterans Affairs determine your eligibility for appointment in the Veterans Health Administration. It collects a variety of personal, educational, and professional information that supports your application to work as a physician, dentist, podiatrist, optometrist, or chiropractor within the VA system.

How do I fill out the form?

Begin by typing or printing your information clearly in ink. Every section must be completed with accurate details. If you run out of space, use a separate sheet and refer to the relevant item number. Ensure you provide sufficient detail for each query so that the VA can properly assess your qualifications.

Is my social security number required?

Yes, the social security number is mandatory. It is essential for the VA to identify your records and to process your application for employment efficiently. The provision of your social security number is mandated under specific federal regulations.

What should I do if I have a pending or revoked licensing issue?

If you have ever had a license revoked, suspended, or are currently facing disciplinary actions, you must disclose this in your application. Be prepared to provide explanations on a separate sheet detailing the circumstances involved, including any current status regarding the issue.

How long will it take to complete the form?

On average, completing the VA Application Physician form should take about 30 minutes. This timeframe includes reading the instructions, gathering necessary information, and filling out the form. Plan to allocate adequate time to ensure thoroughness.

What happens if I provide false information?

Providing false information on your application can have serious repercussions. It may not only disqualify you from obtaining employment but can also result in termination after hiring. Additionally, false statements may lead to criminal penalties under U.S. law.

What are the next steps after submission?

After you submit the form, the VA will review your application and may reach out for further information or clarification. They will conduct background checks to verify your qualifications and suitability for employment within the Veterans Health Administration. Patience is important during this process, as it may take some time before you receive feedback.

Common mistakes

Filling out the VA Application Physician form can be a straightforward process if approached carefully. However, many applicants make common mistakes that can delay their application or jeopardize their eligibility. One frequent error is neglecting to include necessary personal information. Fields such as the applicant's full name, date of birth, and social security number are mandatory. Omitting them can lead to immediate rejection of the form. Always double-check that these crucial details are complete and clearly written.

Another mistake often made is failing to provide thorough explanations when required. For instance, if you answer "yes" to questions about prior applications to the VA or regarding any disciplinary actions, it is critical to offer comprehensive details on a separate sheet. Not providing adequate context may raise red flags during the evaluation process. Ensure you address all questions fully, recognizing that the application is a holistic view of your professional history.

Applicants sometimes overlook the importance of accuracy in providing licensing and certification information. It's not uncommon for someone to incorrectly record their license number or misstate the status of their DEA certification. Small errors in this section may require lengthy corrections, leading to delays. Before submitting your application, confirm that all reported numbers match your official documents.

Additionally, neglecting to keep a consistent timeline of employment and education can create confusion. Ensure that the dates and sequences of your professional experiences align correctly. A confusing chronology can prompt further scrutiny and even potential disqualification. Create a summary of your professional timeline before filling out the form to help maintain clarity.

Lastly, many applicants do not take the time to read or follow the provided instructions carefully. This includes understanding how to fill out the form and where to make necessary signatures. Ignoring instructions can lead to missteps that could easily have been avoided. Set aside time to review the instructions thoroughly to ensure complete and accurate submission. When approached systematically, filling out the VA Application Physician form can be a smooth and successful experience.

Documents used along the form

When applying for a position within the Veterans Health Administration, several additional forms and documents are often necessary. These support your application and provide the necessary background information for processing your request. Below is a list of documents commonly required alongside the VA Application Physician form.

  • Curriculum Vitae (CV): A detailed summary of your professional history, education, and skills. It offers a comprehensive view of your career path and qualifications.
  • Employment Verification Letter: A document from previous employers confirming your work history, job title, and dates of employment. This helps validate your experience.
  • Medical License: A copy of your current state medical license, demonstrating your legal eligibility to practice medicine in that state.
  • Board Certification Documentation: Evidence of certification from a recognized board in your specialty. This confirms your expertise and qualifications in that area of medicine.
  • DEA Registration Certificate: A copy of your Drug Enforcement Administration registration, necessary for prescribing controlled substances.
  • Professional Liability Insurance: Documentation proving that you hold current professional liability insurance, protecting against malpractice claims.
  • References List: A list of professional contacts who can vouch for your qualifications and character, typically including four names and their contact details.
  • Authorization for Release of Information: A signed document that permits the VA to obtain your background information from various agencies, ensuring compliance with their verification process.
  • Social Security Card: A copy of your social security card as it is required for identification purposes and to ensure proper processing of your application.
  • Transcript of Medical School: Official records from your medical school detailing your educational achievements and qualifications.

Having these documents well-prepared can streamline the application process and improve your chances of securing a position. Make sure to check each specific requirement based on the regulations and guidelines provided by the Veterans Health Administration.

Similar forms

The VA Application Physician form shares similarities with several other key documents in the application process for healthcare positions. Each of these forms or documents has a distinctive function but often requires similar types of information. Here are seven documents that exhibit these parallels:

  • Application for Federal Employment (SF-171): Like the VA form, this application collects personal information, employment history, and qualifications from applicants seeking positions in federal government agencies.
  • Credentialing Application: This document is used by healthcare organizations to verify the qualifications of medical professionals. It typically requests details about education, licensure, and professional experience similar to the VA form.
  • National Practitioner Data Bank Self-Query: Medical professionals often complete this form to obtain information about themselves from the National Practitioner Data Bank. This process is similar as it concerns professional background and potential malpractice claims.
  • State Medical Board Application: Applicants for licensure with state medical boards frequently provide comprehensive personal and professional information. This is akin to the details requested on the VA Application Physician form.
  • Clinical Privileges Application: Institutions request this application to grant medical staff specific privileges. Information about qualifications and prior experiences are generally required, paralleling the VA's requests.
  • Professional Liability Insurance Application: This document requires information about a healthcare provider's practice and history, focusing on past claims or incidents, much like the inquiries on the VA form regarding professional conduct.
  • Medical Staff Appointment Application: Often required for hospitals and clinics, this application verifies an applicant’s qualifications, education, and past employment, echoing the structure of the VA Application Physician form.

Dos and Don'ts

Things You Should Do:

  • Carefully follow the instructions provided on the form to ensure all necessary information is included.
  • Use clear and legible handwriting, or type the information to avoid any misinterpretations.
  • Ensure that all mandatory fields are accurately completed, as missing information can delay the application process.
  • Double-check your responses and ensure everything aligns with your supporting documents before submission.

Things You Shouldn't Do:

  • Do not leave any mandatory fields blank, as this may result in your application being rejected.
  • Avoid using abbreviations or unclear terms that could cause confusion regarding your qualifications.
  • Do not provide false or misleading information on the application, as this can lead to disqualification or legal repercussions.
  • Refrain from submitting your application without making a copy for your personal records.

Misconceptions

Misconceptions can often cloud the understanding of important processes such as the VA Application Physician form. Here are ten common misconceptions along with clarifications to help individuals navigate the application process more effectively.

  1. Misconception: The application process is overly complicated.

    While the form may seem lengthy and detailed, it is designed to collect essential information for determining eligibility. Many applicants find it manageable once they begin filling it out.

  2. Misconception: Submitting the application guarantees a job.

    Filling out the application is just the first step in a selection process. Employment opportunities depend on various factors including qualifications and the availability of positions.

  3. Misconception: Only U.S. citizens can apply.

    This is not entirely accurate. While most applicants are U.S. citizens, there is a provision for non-citizens who meet specific criteria to apply, as long as they complete the necessary sections.

  4. Misconception: Past legal issues will disqualify me automatically.

    Each case is assessed individually. The nature and circumstances of any legal issues matter significantly, and applicants are encouraged to provide complete information.

  5. Misconception: The VA does not consider volunteer experience.

    Volunteer work can contribute positively to an application. Relevant volunteer experience, especially in healthcare, can reflect a candidate's commitment and skills.

  6. Misconception: Licensing requirements are not important.

    All applicants must provide evidence of licensure in the states where they wish to practice. Lack of accurate or current licensing information can hinder the application process.

  7. Misconception: Additional sheets should not be used.

    In instances where space is insufficient, applicants are encouraged to attach separate sheets. However, it is essential to reference the items being answered by number.

  8. Misconception: I can leave mandatory fields blank.

    Mandatory fields, such as name and social security number, must be completed for the application to be considered valid. Omitting required information can delay processing or result in rejection.

  9. Misconception: I must submit all documents at once.

    Applicants can send documents as they become available. However, it is advisable to check the requirements and ensure that all necessary information is submitted in a timely manner.

  10. Misconception: The VA does not disclose what happens to my information.

    Detailed information about how personal data is handled is provided in the form's instructions. The VA is obligated to maintain privacy and confidentiality concerning application data.

Understanding these misconceptions can facilitate a smoother application process for those seeking employment with the Veterans Health Administration.

Key takeaways

Understanding how to fill out and utilize the VA Application for Physicians form can enhance the application process and increase your chances for successful employment. Here are six key takeaways:

  • Complete Information is Crucial: Ensure all sections are filled out in detail. Incomplete applications can lead to delays or denials.
  • Mandatory Fields: There are certain fields, like your name and Social Security number, that must be completed. Omitting these can result in immediate rejection of the application.
  • Use Appropriate Documentation: If you require additional space to provide information, attach a separate sheet clearly referencing the related question number.
  • Accuracy Matters: Double-check your entries to avoid mistakes. Any inaccuracies, especially in professional history or qualifications, could jeopardize your application.
  • Familiarize Yourself with Policies: Understanding how the VA uses the information provided, particularly regarding privacy and disclosure, can help you feel more secure in your submission.
  • Seek Assistance if Needed: If unsure about any part of the form, consider seeking guidance from a colleague or professional experienced in VA applications. This can help clarify any complexities.

Browse Other Templates

Stock Power Refers to - If not transferring all shares, specific numbers must be entered for each share type.

How Can I Enroll My Child in a Different School District - Completing the form correctly minimizes any delays in the student’s enrollment at their new school.