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:

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