Interested? Just fill out the application form here:

Clinician Intake Form

Locums United

First Name *

Last Name *

Date of birth *

Email *

Phone *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Locums United. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Address

Street Address *

City *

State *

Country *

Postal code *

Which active state licenses do you have? (Choose all that apply) *

If you hold any other state licenses not listed above, please specify them below.

Please provide the corresponding active state medical license numbers, separated by commas if you have multiple. *

Have you completed a residency in the United States? *

What year did you complete your residency? *

Which of the following open jobs are you applying for? *

Were you referred to this job? If yes, please share the name of the person.

If you weren't referred to this job, where did you hear about this job?

Acknowledgement: *

Disclaimer: By applying for this position, you acknowledge that you are being presented to this site for consideration to work a locum assignment with this hospital through Locums United. If at any point you wish to withdraw your application, you may do so by replying “Withdraw” to this email or SMS text. However, please note that once you have agreed to be presented for this opportunity, you cannot withdraw your affiliation with Locums United for this opportunity.

Do you have the Interstate Medical Licensure Compact (IMLC) Certificate? *

Yes

Which of the following certifications apply to you? *

What is your medical speciality? *

If you have any other medical speciality, please specify.

What is your board certification status? If you are board certified, please specify the name of the board. *

What is the minimum number of shifts per month you are available for? *

At the majority of sites we work with, a minimum commitment of 4-5 shifts per month is typically required.

What is the earliest date you can start picking up locum shifts? *

What is your NPI number? *

To help us match you with the most suitable opportunities, can you share any practice restrictions, red flags, or past disciplinary actions, if applicable? This does not automatically disqualify you but allows us to support you better. *

Please disclose any restrictions, red flags, or disciplinary actions on your record.

Please upload your CV. *

Upload your CV here

Please provide a personal (non-work-related) emergency contact, such as a family member or close friend. *

Please provide the phone number of your emergency contact. *

Please provide details for at least two clinical references. Include their name, job title, email, phone number, and the facility where you worked together.

Details for Reference # 01:

Full Name: *

Email:

Phone Number: *

Job Title: *

Facility: *

Details for Reference # 02:

Full Name: *

Email: *

Phone Number: *

Job Title: *

Facility: *

Compliance and Conduct Acknowledgement *

I acknowledge that I am responsible for understanding and complying with all applicable federal, state, and professional laws, regulations, and ethical standards governing my practice as a Physician Assistant. This includes, but is not limited to, the Health Insurance Portability and Accountability Act (HIPAA), Stark Law, Anti-Kickback Statute, Occupational Safety and Health Administration (OSHA) workplace safety regulations, Drug Enforcement Administration (DEA) prescribing rules (if applicable), Medicare and Medicaid billing requirements, state-specific Physician Assistant Practice Acts and licensing rules, telemedicine and controlled substance prescribing regulations, and professional codes of conduct including the American Academy of Physician Assistants (AAPA) Code of Ethics, National Commission on Certification of Physician Assistants (NCCPA) Code of Conduct, Federation of State Medical Boards (FSMB) Model Guidelines for Physician Assistants, and the Joint Commission’s professionalism and conduct standards where applicable. I understand that failure to comply with these requirements may result in disciplinary action, including termination, loss of licensure or certification, and/or legal consequences.