www.cmastaffing.net
678-325-0717
PROVIDER REGISTRATION
Please complete the form below, all items with an "*" are required.
PERSONAL INFORMATION
First Name
*
Middle Name
Last Name
*
Street Address 1
*
Unit #
City
*
State
*
Zip Code
*
Phone 1
*
Phone 2
Email
*
PROFESSIONAL INFORMATION
Degrees
*
State(s) Licensed
*
Medical Specialty
*
Board Status
*
MALPRACTICE INFORMATION
Has your professional liability insurance coverage ever been terminated or not renewed by action of the insurance company?
*
Select One
No
Yes
If yes please provide date, name of company, and basis for termination or non-renewal.
Have there ever been any professional liability (i.e. malpractice claims, suits, judgments, settlements, or arbitration) proceedings involving you?
*
Select One
No
Yes
Are any professional liability (i.e. malpractice claims, suits, judgments, settlements, or arbitration proceedings) involving you currently pending?
*
Select One
No
Yes
Are you aware of any formal demand for payment or similar claim submitted to your insurer that did not result in a lawsuit or other proceeding alleging professional liability?
*
Select One
No
Yes
OTHER INFORMATION
Please include any additional information you'd like to share with us.
You may upload your CV here (optional).
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CMA Staffing
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330 Longvue Ct.
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Duluth GA 30097
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Phone: 678-325-0717
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