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Get Consilium Staffing Physician Document Checklist 2015-2024

Ges, and sign and date the last page. Provider Service Agreement (PSA) Sign and Date last page. Release and Authorization (R & A) Print your name, sign, and date. Current Curriculum Vitae (CV) The CV must include your work history from receipt of medical degree to present. All dates must include month and year and not contain any gaps in time. Independent Contractor Declaration This form acknowledges that you are an independent contractor. Print your name, sign and date. W-9 Must in.

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