3033 S. Parker Rd., Suite 606
Aurora, CO 80014
(303) 832-7493 / (800) 851-6782
Fax: (303) 832-7496
Email: info@coruralhealth.org


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Provider Form:
Providers interested in receiving detailed information regarding practice opportunities in rural and underserved communities in Colorado should first complete the Provider Interview Form. Provider information will be kept confidential and will not be provided to third parties until provider approval has been received.

Contact Information
Prefix
First Name:
Middle Name:
Last Name:
Address:
City, State, Zip:
Telephone (Home):
Telephone (Work):
Email:
Citizenship Status  
How did you hear about the CPR program?  
Other
May we contact you?  
Where should we contact you? (Check all desired)



Loan Repayment
Loan repayment needed?
Please specify which Loan Repayment Programs you are interested in or obligated to:  
Are you a NHSC Scholar?   Please indicate obligation:
If you are not a NHSC Scholar, will you be applying for NHSC Loan Repayment?  



Position Seeking
Type of Health Care Provider
Other (Please Specify)
Specialty
Other (Please Specify
Date of Availability
  

 

Education Information



Medical School / Graduate School
Undergraduate School  
Undergraduate School City/State  
Undergraduate Graduation Date (MM/DD/YY)  
Medical School / Graduate School Attended:
City/State of Medical/Graduate School:
Date Graduated (MM/DD/YY):


Board and License
Are you Board Certified?
If boarded, how are you boarded?:

If other, please specify:
FLEX Boards specify number of sittings:

Are you licensed?: In which states:



Residency Program
(if applicable)
Name of Residency Program:
Date Completed (MM/DD/YY):
Current/Previous Work Experience
Location:
Type:
Description:
Number of Years:
Location:
Type:
Description:
Number of Years
 


Type of Practice Preferred
Practice Setting Desired:

First Choice

Second Choice

Third Choice

Other

Comments on Geographical Needs:  
What are your minimum salary requirements?  
Will you perform OB services?  
Will you accept Medicare/Medicaid Patients?  


General Colorado Location Preferred
Colorado Location Preferred:
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First Choice

Second Choice

Third Choice

Other

Community Size Preference:  
Factors in Community Selection:  
Services Trained For and Willing to Perform:
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Other Services


Cultural Competencies
Select all that apply:
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Please specify other languages:


Educational Resources Needed in Community
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Other Resources Needed:


Religious Resources Needed in Community
Select all that apply::
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Other Religious Affiliation Needed:


Cultural Entertainment Desired in Community
Check all that apply::
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Other Entertainment Desired:


Recreational Activities Desired in Community
Select all that apply:
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Other Activities Desired:
Personal Data
Date of Birth (MM/DD/YY)  
Marital Status  
Spouse/Sign. Other Name:
Spouse/Sign. Other Work:
Number of Children with ages:  
Family Member Needs/Interest  
Long-term Professional Goals:  
Additional Comments:  

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