• (Any deliberate inaccuracy on the application will result in an automatic denial)
  • (Any red flags or false information on the resume will result in automatic denial)
  • (Any red flags or false information on the interview will result in automatic denial)
  • (If all answers to the questionnaire are NO, this section will be approved. Answers YES to questions 1, 2, 3, 7, 8, 9, 10, 12, 13, 14, 15 will be reviewed on a case by case basis. Answers YES to questions 4, 5, 6, 11 will result in an automatic denial).
  • (Minimum 3 referenced must be provided. If the applicant is three years within completion of training, one of the references must be program director. If all answers to questions are Satisfactory/outstanding, No to health status and applicant is recommend without reservation this portion will be approved. If any answers to questions are unsatisfactory and answer to health status is yes and there are reservations about the applicant; this will be reviewed on a case by case basis. Any references indicating “do not recommend the applicant” will result in automatic denial.)
  • (Claims history will be verified by MRS staff. Any history will be reviewed by the medical director and a case by case basis. Any court judgment against the provider will result in automatic denial)
  • (MRS will verify accuracy).
  • (must be verified by MRS).
  • (must be verified by MRS).
  • (must be verified by MRS).
  • (any criminal history will result in automatic denial).
  • (Any sexual abuse history will result in automatic denial).
  • Medical Director: Ahmed El-Emawy, MD
  • Date Format: MM slash DD slash YYYY