Consultant Information / Become A Consultant   Step 1 of 3 Participating Reviewer Application   Applicant's Name:   Mailing Address: Address1 Address2 City State AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WV WI WY Zip Fax Number:       Cell Phone: Pager: E-mail Address:         Office Locations:                  Primary Additional Office Contact Person:                                                                                                         Name Title Phone               Tax ID # and Corporation Name (If Applicable):   Tax ID Corporation Professional License(s):  Include State, License Number Expiration Date, Status (Active/Inactive)   State License # Expiration Status Please Select AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WV WI WY Please Select Active Inactive Not Registered Suspended Revoked Surrendered Please Select AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WV WI WY Please Select Active Inactive Not Registered Suspended Revoked Surrendered Please Select AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WV WI WY Please Select Active Inactive Not Registered Suspended Revoked Surrendered            Board Certifications: If there are none please enter the word "none".        Specialty Year of Certification                       Practice Focus:       Current Level of Practice: Active   Please Select Yes No Number of hours/week   Teaching   Please Select Yes No Others   Name of Malpractice Insurer: Describe any license suspensions or limitations on your license or activities. If there are none please enter the word "none".        List any area of potential conflicts of interest:                                                                    Testifying Experience: Worker Compensation Please Select Yes No Civil Litigation Please Select Yes No No Fault Arbitration Please Select Yes No Days available to testify   Languages other than English:   Hospital affiliation(s) and staff status:   History of sanctions and disciplinary actions: Professional References (list two): Percentage of  Practice: What percentage of your practice is dedicated to independent reviews and examinations?    Stake-Holder: Are you personally a stake-holder in any Independent Review Organization, or any other such organization that performs services and duties similar to that of Crossland Medical Review Services Inc? No Yes   Please be sure to review your information for accuracy, as you will not be able to correct it once you click on the NEXT button. Please do not use the BACK button on your browser. Also, if multiple doctors are entering information from the same location, please close and re-open your browser before filling out the on-line form. Failing to due so will inhibit the information previously entered from being submitted. If you need to make a correction after you have already submitted your information, please contact Crossland Medical Review Services at 516-677-1114.