Member Login - Blue Moon Chiropractic Temp Agency

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TEMP DOCTOR DAY SHEET

Your Name:(Required)

First

Phone Number:(Required)

Email Address:(Required)

Today’s Date:(Required)

MM slash DD slash YYYY

Clinic Covered:

Coverage Location

City County / State / Region

Dates Worked:(Required)

For each day:

Full Day / Half Day?(Required)

Full Day

Half Day

Number of Patients Seen:

Hotel?

Yes

Payment Summary:

Total Full Days x Daily Fee(Required)

Total Half Days x Daily Fee(Required)

TOTAL(Required)

Payment will be sent within 10 days of receiving your completed form.

TEMP DOCTOR APPLICATION FORM

(All fields below are required unless marked optional)

Personal Info

Last Name:

First Name:

Date of Birth:

Cell Phone:

Other Phone (optional):

Email:

Home Address:

City:

State:

Zip Code:

Country:

Social Security Number (never shared):

Languages Spoken (besides English):

Education

Undergraduate School(s):

Chiropractic College Attended:

Graduation Date:

Techniques Used:

Other Techniques or Notes:

License Info

Date of First License:

License(s) Held:

Country:

State:

License # and Expiration:

Current Malpractice Insurer:

Previous Malpractice Insurer (if applicable):

Work History (Minimum 3 Years)

Clinic Owner Name:

Clinic Address:

City/State/Zip:

Dates Worked (From–To):

Practice History Questions

Have you ever had any malpractice claims (open or closed)?
Yes No
If yes, explain:

Has your license ever been denied, revoked, suspended, or had disciplinary action?
Yes No
If yes, explain:

Have you ever been excluded from Medicare/Medicaid or CAQH plans?
Yes No
If yes, explain:

Have you ever been convicted of a crime or misdemeanor?
Yes No
If yes, explain:

Has your malpractice insurance ever been suspended, canceled, or limited?
Yes No
If yes, explain:

Are you currently suffering from any communicable disease?
Yes No
If yes, explain:

Do you suffer from a substance abuse disorder or mental condition?
Yes No
If yes, explain:

Notifications

Do you agree to receive email/text alerts from BMCA about open coverage jobs?
Yes No

Disclaimer
My role is solely to act as a professional liaison, facilitating connections between licensed chiropractors seeking temporary work and clinics in need of coverage. This service functions as a vetted matchmaking platform and does not employ or contract chiropractors directly.

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