1. Application(Any deliberate inaccuracy on the application will result in an automatic denial)ReceivedReviewedApprovedDenied2. Resume(Any red flags or false information on the resume will result in automatic denial)ReceivedReviewedApprovedDenied3. Interview(Any red flags or false information on the interview will result in automatic denial)PendingPerformedApprovedDenied4. Professional questionnaire(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).ReceivedReviewedApprovedDenied5. Professional references(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.)ReceivedReviewedApprovedDenied6. Claims history(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)ReceivedReviewedApprovedDenied7. NPI numberVerified8. Copy of educational certificate as applicable (Master of Science in Nursing (MSN), Doctor or Nursing Practice (DNP), Master in Physician Assistant Studies (MPAS), Medical School Diploma, Residency Certificate, Fellowship Certificate if applicable).(MRS will verify accuracy).ReceivedReviewedApprovedDenied9. Training certificates as applicable (BLS, PALS, NRP, ACLS, ATLS, ALSO etc)ReceivedReviewedApprovedDenied10. Copy of medical license per state(must be verified by MRS).ReceivedReviewedApprovedDenied11. Copy of controlled substance registration certificate if applicable(must be verified by MRS).ReceivedReviewedApprovedDenied12. Copy of federal DEA registration(must be verified by MRS).ReceivedReviewedApprovedDenied13. Consent, authorization for release of information and release of liability form must be signed by applicantReceivedReviewedApprovedDenied14. Federal and state criminal background check(any criminal history will result in automatic denial).PerformedApprovedDenied15. Sexual abuse registry(Any sexual abuse history will result in automatic denial).PerformedApprovedDenied16. MRS must receive written confirmation in the form of email or letter from potential providers prior to presenting them to potential clients.PendingReceived17. Checklist will be reviewed by medical director:Pending reviewReviewedApplication StatusApplication approvedApplication deniedMedical Director: Ahmed El-Emawy, MDSignatureDate Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
