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Section VI - Specialty / Board Certification

Primary Specialty Designation
Secondary Specialty Designation
Certification Questions
Life Support Certification

Primary Specialty Designation

Primary (in which you spend 50% or more of your time):

Certification Number (if applicable):

Specialty Board:

Do you have clinical privileges at any hospital in the specialty noted?

Yes No

Lifetime?

Yes No

Initial Certification Date

Last Certification Date

Expiration Date:

Maintenance of Certification

Required to participate in MOC?

Yes No

Participating in MOC?

Yes No

Secondary Specialty Designation

Secondary Specialty Designation:

Certification Number (if applicable):

Specialty Board:

Do you have clinical privileges at any hospital in the specialty noted?

Yes No

Lifetime?

Yes No

Initial Certification Date

Last Certification Date

Expiration Date:

Maintenance of Certification

Required to participate in MOC?

Yes No

Participating in MOC?

Yes No

Certification Questions

Have you ever failed a Board Exam ?

Yes No

If you are not currently Board certified, are you pursuing certification?

Yes No

B.L.S.

Certification Number (if applicable):

Expiration Date

A.L.S.

Certification Number (if applicable):

Expiration Date

P.A.L.S.

Certification Number (if applicable):

Expiration Date

Save & Continue

Progress List

Pre-Application Questions Completed
Basic Details In Progress
Clinical Work History Missing Info
Education Completed
CME Not Started
Licenses Not Started
Certifications Not Started
Professional Liability Insurance Not Started
Claims History Not Started
References Not Started
Attetation Questions Not Started
Background Check Not Started
Acknowledgments Not Started
Confidentiality Agreement Not Started
Information Release Not Started

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