Physician Application Link | Job Requisition

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1Facility Information and Need

2Practice Details

3Contacts

4Professional Requirements

Client Name: *

Practice Type:

Facility Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person Name: *

First

Last

Contact Phone Number: *

Contact Email: *

How did you hear about Krewe?

May we have the name/company of the person who referred you?

Type of Healthcare Professional Needed: *

Anesthesiologist
Other

Specialty or Specialties Needed:

Number of Professionals Needed:

Reason for Need:

Additional information regarding need:

Duration of Need:

Assignment Target Start Date:

Special Requirements or Notes:

Shift Details:

8
10
12
16
24
Night
Weekday Call
Weekend Call

Minimum hours paid when called back in:

how Name: Credentialing

Do you require candidates to interview?

Will you accept New Grads?

No
Yes
Tell me about Krewe's New Grad First-Year Flex Program

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Worksite Address (if different from previously entered location):

Address Line 1

Address Line 2

City

State

Zip Code

If the providers will work at any other location(s), please list them here:

Organization/Affiliate:

How many anesthesiologists are in your group?

Number of operating rooms:

Documentation system:

(Cerner, Epic, Paper, etc.)

What is the average privileging timeframe?

How long are privileges valid for?

Do you offer temporary privileges for a quick turnaround if needed?

Are there approval meetings?

If so, how often?

When is the next meeting?

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Credentialing Contact:

First

Last

Credentialing Contact Phone:

Credentialing Contact Email:

Orientation Contact:

First

Last

Orientation Phone:

Orientation Email:

Billing Contact:

First

Last

Billing Phone:

Billing Email:

Candidate Submission Contact:

First

Last

Candidate Submission Phone:

Candidate Submission Email:

Time Card Approval Contact:

First

Last

Time Card Approval Phone:

Time Card Approval Email:

After-hours Emergency Contact

First

Last

After-hours Phone:

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Is the Physician required to be certified in the following?

BLS
ACLS
ATLS
ABLS
PALS/APLS
NRP
DEA License

Anesthesia Areas and Procedures

Please mark the most applicable choice for each item in this section:

General Anesthesia (Adult)

Required
Preferred
Not Required

General Anesthesia (Pediatric)

Required
Preferred
Not Required

General Anesthesia (Neonatal)

Required
Preferred
Not Required

General Anesthesia (Trauma)

Required
Preferred
Not Required

Spinal Anesthesia

Required
Preferred
Not Required

Epidural Anesthesia

Required
Preferred
Not Required

Regional Anesthesia

Required
Preferred
Not Required

Obstetrical Cases

Required
Preferred
Not Required

Neurosurgical Cases (Head)

Required
Preferred
Not Required

Neurosurgical Cases (Spine)

Required
Preferred
Not Required

Open Heart Anesthesia

Required
Preferred
Not Required

Thoracic Cases (except Open Heart)

Required
Preferred
Not Required

TAVR

Required
Preferred
Not Required

Complex Vascular Cases (except Open Heart)

Required
Preferred
Not Required

Endoscopy

Required
Preferred
Not Required

Cath Lab

Required
Preferred
Not Required

Pain Management Techniques

Required
Preferred
Not Required

Post-Op Epidural

Required
Preferred
Not Required

Post-Op Extremity Blocks

Required
Preferred
Not Required

Use of Ultra-Sound in Placement of Blocks

Required
Preferred
Not Required

Insertion of Central Line

Required
Preferred
Not Required

Insertion of Arterial Line

Required
Preferred
Not Required

Other requirements or comments:

Management of: PA Catheter

Required
Preferred
Not Required

Name *

Title *

Signature *

Clear Signature

Date *

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Anesthesia Areas and Procedures

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