Application For A License To Practice Podiatric Medicine Page 19
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24ALASKA STATE MEDICAL BOARD
MED
Department of Commerce, Community, and Economic Development
For Office Use Only
Division of Corporations, Business, and Professional Licensing
(333 Willoughby Avenue - Ninth Floor)
Post Office Box 110806
Juneau AK 99811-0806
A – K: 907/465-2756
L – Z : 907/465-2541
E-mail:
medicalboard@alaska.gov
VERIFICATION OF
HOSPITAL PRIVILEGES
Instructions to the Applicant:
Please complete Part I below. Forward a copy of this form to each hospital where you have held privileges in the
immediate past five years. Include privileges held during residency. Copy this form as needed. Please type or print
legibly. Part II is to be completed by the hospital staff office.
PART I
Full Name (Last, First, Middle)
Maiden or Other Names Used:
Date of Birth (MM/DD/YYYY)
Mailing Address
City
State
Zip
Signature of Applicant
Date of Signature
Name of Hospital
_____________________________________________________________________
Mailing Address
_____________________________________________________________________
City/State/Zip
_____________________________________________________________________
FOLLOWING TO BE COMPLETED BY HOSPITAL STAFF ONLY
PART II
Instructions to the Hospital:
I am applying for a license to practice medicine in Alaska. The Alaska board requires this form to be completed by each
hospital where I have held privileges in the past five years. Please complete this form by answering the questions below
and mailing this form directly back to the Alaska board at the letterhead address.
1
Dates of Hospital Privileges:
From__________________________
To__________________________
2
Has your hospital ever taken any disciplinary action against this physician?
No
Yes
3
Have there ever been limitations or restrictions on this physician’s privileges?
No
Yes
4
Are any disciplinary actions pending against this physician?
No
Yes
5
Is there any derogatory information on file regarding this physician?
No
Yes
6
Is there any reason you would not readmit this physician to your medical staff?
No
Yes
If you answer “Yes” to any question above, please attach a detailed explanation signed and dated by the person whose signature appears below.
Signature____________________________________
Printed Name________________________________
Original signature only, signature stamps are not accepted.
Title____________________________________
Date_________________________________
Telephone___________________________________
08-4109d (Rev. 10/15/14)
Hospital Verification
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