logo
Menu
Become a Volunteer Graphical header

Physician Shadowing Application

This application is a request by the person named below (“Applicant”) to participate in the Pikeville Medical Center Physician Shadowing Program (“Program”).  Submission of this application does not guarantee that applicant will be selected to participate in the Program.

First Name:
Middle Name:
Last Name:
Are you 16 or older? Yes No
Date of Birth:
Home #:
Cell #:
Email Address:
Present Address:
SSN:
Timeframe of shadowing request:
Emergency Contact:
Name:
Phone #:
I represent and warrant that I am not now nor have I ever been (i) listed by an agency or entity as excluded, debarred, suspended, or otherwise ineligible to participate in any federal, state, or private health care benefit program; (ii) listed as an excluded party by the U.S. Department of Health and Human Services or General Services Administration; (ii) been charged with, convicted of, pled guilty to, or entered a plea of non contendere (or any similar plea) with respect to any healthcare related offense; or (iv) been sanctioned for any form of healthcare fraud or abuse. I will notify Pikeville Medical Center immediately upon the commencement of any proceeding against me in which the outcome may be any of the above-described events.

I further agree to execute any documentation necessary to comply with PMC’s vaccination policy, including any authorizations to release my protected health information or otherwise apply for an appropriate exemption. I agree that before I can be accepted as a physician shadow I must comply with PMC’s vaccination policy and failure to comply may lead to me not being accepted as a physician shadow or being dismissed as a physician shadow.


I hereby attest that all of the foregoing information is true and correct. I authorize Pikeville Medical Center to obtain such background and personal reports as are deemed necessary to verify that the information I have supplied is true and accurate. A copy of this authorization is valid as the original.
Participant Signature:
Date:
If younger than 18 years of age, please have a Parent/Legal Guardian read and sign the following:



I hereby attest that I am the Parent/Legal Guardian of the Applicant and that all of the foregoing information is true and correct. I authorize Pikeville Medical Center to obtain such background and personal reports regarding the Applicant as are deemed necessary to verify that the information I have supplied is true and accurate. A copy of this authorization is valid as the original.
Parent/Legal Guardian Signature:
Date:

 

>>><<<

Latest News and Events

    • NOVEMBER 5, 2018
    PMC Able to Target Radiation Directly to Surface of Skin Cancer

    PMC Able to Target Radiation Directly to Surface of Skin Cancer

    Pikeville Medical Center (PMC) today announced it has adopted the Xoft® Axxent® Electronic Brachytherapy (eBx®) System®, an advanced technology able to deliver a targeted dose of radiation directly to the surface of nonmelanoma skin cancer (NMSC) lesions. The Xoft System is FDA cleared for the treatment of cancer anywhere in the body, including early-stage breast

    Read more
    • NOVEMBER 1, 2018
    PMC Works to Reduce Lung Cancer Incidences with Advanced Screening Technologies

    PMC Works to Reduce Lung Cancer Incidences with Advanced Screening Technologies

    Lung cancer kills more Kentuckians every year than the next eight most common cancers combined. Pikeville Medical Center (PMC) is working to reduce lung cancer incidences and deaths in the state through advanced screening technologies. “Of all the cancers that are treated at PMC, we see more cases of lung cancer than any other,” explained

    Read more
© 2013-2022 Pikeville Medical Center, all rights reserved.
Pikeville Medical Center