Form 0917-0009 Statement of Health

Statement of Health
Check one of the health statements below, by my signature hereto,
I represent that presently, and for five years prior to the date of my signature, I do
not have, have not had, and have not been diagnosed and/or treated as having any
illness, condition or symptom relating to any physical or behavioral health condition
that would impact in any manner upon my ability to either practice medicine in
general, or perform any of the functions in particular that are set out in the position
description of the position for which I am presently applying.
I have an impairment that affects my ability to perform the clinical privileges
requested and for which I require special accommodation.
Reasonable accommodation needed: __________________________________
I have an impairment that DOES NOT affect my ability to perform the clinical
privileges requested. NO special accommodations are needed.

Applicant’s Signature

Date

Confirmation of health status on initial appointments must meet the facility's
accrediting body standards and governance documents. The confirming health care
practitioner may not be related to the applicant by blood or marriage.
I hereby confirm that the provider identified above
does
does not currently
have any health problems (including disability, emotional stability, drug, or alcohol
dependency) that might impair his/her ability to care for patients.

Name (Printed or Typed)

Signature

Title/Degree

Date