Physicians Directory

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Name

Ed D Townsend

Email
Profession

NP

Primary Specialty

Hospitalist

Telephone Number

575 894 2245

Best way to reach

Email

Resume

THEMAC-Outreach-Flyer_April-201226.pdf

Medical Diploma

THEMAC-Outreach-Flyer_April-201227.pdf

Fellowship Certificate

THEMAC-Outreach-Flyer_April-201229.pdf

NRP Certificate

THEMAC-Outreach-Flyer_April-201230.pdf

BLS CERTIFICATE

THEMAC-Outreach-Flyer_April-201231.pdf

ALSO CERTIFICATE

THEMAC-Outreach-Flyer_April-201232.pdf

ACLS CERTIFICATE

THEMAC-Outreach-Flyer_April-201233.pdf

PALS CERTIFICATE

THEMAC-Outreach-Flyer_April-201234.pdf

ATLS CERTIFICATE

THEMAC-Outreach-Flyer_April-201235.pdf

FEDERAL DEA REGISTRATION CERTIFICATE

THEMAC-Outreach-Flyer_April-201236.pdf

CONTROLLED SUBSTANCE REGISTRATION

THEMAC-Outreach-Flyer_April-201237.pdf

Medical License

THEMAC-Outreach-Flyer_April-201238.pdf


Application


Degree

C.H.A.

Place of Birth

Chicago

Date of Birth

05/14/1931

Social Security Number

12 345 6789

NPI Number

1122

Address

555 N North St

City

T or C

State

NM

Zip

87901

Board certification status
  • Certified
Specialty

---Select---

Date of certification
List all states in which you are currently or have been licensed to practice in

NM


PROFESSIONAL REFERENCES: Minimum three references required

Professional Questionnaire


1. Has your state license in any jurisdiction ever been investigated, voluntarily or involuntarily limited, suspended, revoked, or are there current pending challenges to any of these items?

No

2. Has your Federal or state narcotics registration certificate in any jurisdiction ever been voluntarily or involuntarily limited, suspended, revoked, restricted, or are there currently pending challenges to any of these items?

No

3. Has your staff appointment or clinical privileges at any hospital ever been voluntarily or involuntarily revoked, restricted, suspended or not renewed?

No

4. Do you use illegal drugs or have you used such drugs in the past?

No

5. Are you currently abusing alcohol?

No

6. Are you authorized to work as an independent contractor in the United States?

Yes

7. Are you capable of performing the essential functions of a locum tenens provider in your speciality with or without reasonable accommodation?

Yes

8. Do you know of any reason why you cannot perform the essential duties of the clinical privileges/functions you are requesting according to acceptable standards of professional performance and without posing a direct threat to patients?

No

9. Do you have reason to believe that you are not in compliance with state and federal regulations regarding tuberculin skin testing, measles, rubella immunity, and required blood borne pathogen training and hepatitis B status?

No

10. Have you ever been named as a defendant in any criminal proceedings, convicted of felony, or subjected to an investigation by a government entity that could result in sanctions or licensure adverse actions?

No

If yes, please explain
11. Have you ever received a DWI/DUI?

No

12. Have you ever been convicted of a felony or misdemeanor, not including a traffic citation?

No

13. Is there any other issue, which you should disclose that may impact your ability to perform your duties as a locum tenens provider?

No

14. Have you ever been named in any formal requests for corrective (Formal or informal) actions filed by any medical staff where you have had any appointment?

No

15. Have you ever been involved in a settlement, medical malpractice claim or suit?

Yes


Claims Information if Any


Claimant name
Claimant age
Claimant sex
Date of alleged error
Location of alleged error
Defendant attorney
Claimant attorney
Other parties involved (Other defendants)
Name of insurer
Telephone number of insurer
Address of insurer
City of insurer
State of insurer
Zip of insurer
Status of complaint
Total payment if applicable
Amount paid
Description of claim (please give a complete narration of the claim including the following: alleged act or error upon which claimant bases claim, description of the type and extent of injury or damage allegedly sustained, patient’s condition at time of your involvement, patient’s condition at end of your treatment).

Claims 2

Claimant name:
Claimant age:
Claimant sex:
Date of alleged error:
Location of alleged error:
Defendant attorney:
Claimant attorney:
Other parties involved (Other defendants):
Name of insurer:
Telephone number:
Address of insurer:
City of insurer:
State of insurer:
Zip of insurer:
Status of complaint:
Total payment if applicable:
Amount paid:
Description of claim (please give a complete narration of the claim including the following: alleged act or error upon which claimant bases claim, description of the type and extent of injury or damage allegedly sustained, patient’s condition at time of your involvement, patient’s condition at end of your treatment):


Consent, Authorization for Release of information and release of liability:


The purpose of this form is for you to grant authority for Medical Resource staffing LLC, employes, representatives and affiliates to gather information from various sources regarding your professional skill, competence and qualifications. It is important that you carefully read and understand this form before signing.

I hereby affirm and acknowledge under the penalties of perjury that the information provided by me on this application and questionnaire is correct, true and complete. I acknowledge that Medical Resource Staffing LLC will rely on the completeness and truthfulness of the information I have provided in evaluating my application and potential placement with Medical Resource Staffing LLC as a locum tenens provider.

By signing the form, I hereby authorize Medical Resource Staffing LLC, employees, representatives and affiliates to obtain and gather information regarding my personal character, ethics, education, training, medical acumen, professional affiliations, professional skill, professional competence, licensure, certificates, criminal history, health and professional liability insurance coverage, claims and litigation history.

I understand and acknowledge that Medical Resource Staffing LLC and specific employees and and representatives will contact and obtain written and/or verbal information from a wide variety of my sources in order to gather this information, including but not limited to: State medical or licensure boards, national practitioner data bank, government databases and exclusion lists, state and federal regulatory agencies and courts, educational and training institutions, professional boards and societies, mentors, peers and former professional relations, medical staff, including department heads, chairs and direct supervisors, insurers, employers and credit report, and if applicable monitor treatment programs.

Initial
Authorization for Release of information:

I consent and authorize the release of all information listed above to Medical Resource Staffing LLC. I further understand the Medical Resource Staffing LLC may use this information for any lawful purpose associated with the processing and review of my application, including but not limited to disclosure to individuals or committees involved in the review of my application.

Initial

I release and discharge Medical Resource Staffing LLC, their representative, employees, governing bodies, clients and affiliates whether or not designated by these titles, and all other persons or entities supplying information information to them from liability or claims of any kind or character in any way arising out of inquiries concerning me or disclosures made in good faith in connection with my application. I am also waiving my right of action or other means of redress I may have against any person or entity supplying this information concerning my background to Medical Resource Staffing LLC or any of their entities to which I am applying as a locum tenens provider. I acknowledge that the decision to be granted a contract as a locum tenens provider with Medical Resource Staffing LLC is solely and completely at the discretion of Medical Resource Staffing LLC.

I authorize Medical Resource Staffing LLC to present my resume for potential assignment as a locums tenens provider at the facility/client of interest as agreed.

Name

Ed Potter

Date

08/23/2018

Signature

NPI Number

2211