*FMC Supervising Physician [MD] Application & Background Disclosure

Application for physicians (MD/DO) interested in supervising Functional Medicine NPs, PAs, and Clinical Pharmacists. This form collects professional, licensure, and background details for credentialing and regulatory compliance.

Full Legal Name *

Email Address *

Phone Number for Texting Purposes *

Address

Street Address *

City *

State *

Postal Code *

Medical Degree *

List any specialty board certifications (Certification & Issuing Board) *

List all states where you hold an active license, have applied for licensure, or have held prior licensure (Include state and license type/number). *

Please indicate the total number of NP/PA providers you are available to supervise for each license listed. *

Primary Specialty *

Do you currently practice telemedicine? *

Are you currently acting as a Supervising or Collaborating Physician? *

If yes, how many practitioners do you currently supervise? *

Are you willing to supervise: *

Are you familiar with supervision regulations in your licensed state(s)? *

Are you willing to dedicate approximately 1–2 hours per month? *

Do you carry malpractice insurance that covers supervisory duties? *

Which services are you comfortable supervising? (Select all that apply) *

Please provide a brief statement on why you are interested in collaborating with Functional Medicine practitioners. *

Have you ever been arrested or charged with a criminal offense (excluding minor traffic violations under $250 not involving drugs/alcohol)? *

Have you ever been convicted, imprisoned, or placed on probation? *

Have you ever been the subject of a grand jury or criminal investigation? *

Have you ever been investigated, disciplined, restricted, or sanctioned by a licensing authority? *

Have you ever withdrawn, surrendered, or been denied a healthcare license? *

Have you ever had restrictions placed on a license or controlled substance permit? *

Have you ever had federal or state controlled substance permits revoked, denied, or restricted? *

Have you ever been involved in Medicare, Medicaid, or insurance fraud matters? *

Have you ever violated a Controlled Substances Act? *

Have you ever been involved in sexual, assaultive, tax fraud, or alcohol-related offenses? *

If you answered YES to any of the above questions, please provide a detailed explanation. (If no, put N/A) *

Have you ever had a complaint or malpractice lawsuit related to patient care? *

Have you ever settled a malpractice claim? *

If yes to any malpractice question above, please explain the circumstances and indicate the number of cases. *

Have you experienced medical school disciplinary action or delay in advancement? *

Have you experienced residency or training probation, investigation, or termination? *

Have you experienced employment termination related to professional conduct? *

If yes to any professional conduct question above, please provide a detailed explanation. (If no, put N/A) *

Are you currently suffering from any condition that impairs your ability to practice medicine safely? *

If yes, please explain the condition and how it is managed. (If no, put N/A) *

By submitting this application, I affirm that all information provided is true, complete, and accurate to the best of my knowledge. I understand that false or misleading information may result in denial of participation or removal from the FMC Network. *

Date of Attestation (MM/DD/YYYY) *