PHYSICIAN REFERRAL SERVICE
 3993 Jurupa Avenue Riverside, CA 92506
(951) 686-3342 FAX (951) 686-1692

 

Please print or type the following:
Name:_____________________________________________________________
Date of Birth:________________ Place of Birth:______________________Sex: M F
Specialty (1)________________ Specialty (2) _____________ Specialty (3)___________
Board Certified (1)___________Board Certified (2) _________Board Certified (3)_______

PRIMARY OFFICE ADDRESS
Street/Suite_________________________________________________________________
City/Zip___________________________________________________________________
Phone#(_________)________________________FAX#(__________)_________________
OFFICE HOURS:
__________________________________________________________________________
__________________________________________________________________________

SECONDARY OFFICE ADDRESS
Street/Suite_________________________________________________________________
City/Zip____________________________________________________________________
Phone#(_________)________________________FAX#(__________)__________________

HOME ADDRESS (NOT FOR PUBLIC DISCLOSURE)
Street______________________________________________________________________
City/Zip_____________________________________________________________________
Phone#(_________)________________________FAX#(__________)___________________

MAJOR HOSPITAL AFFILIATIONS:
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________
4. _______________________________________________

I WILL ACCEPT REFERRALS FOR:

MEDI-CAL

MEDICARE

MEDICARE/MEDI-CAL CROSSOVER

MEDICARE ASSIGNMENT

HOUSE CALLS

CONVALESCENT HOSPITAL VISITS

CONTINGENCY (LIEN)

CASH INSTALLMENTS

PROJECT K.I.N.D.

FOREIGN LANGUAGES SPOKEN BY PHYSICIAN OR STAFF:

1. _________________________________________
2. _________________________________________
3. _________________________________________

PHYSICIAN REFERRAL SERVICE
PARTICIPATION AGREEMENT

As a member of the Riverside County medical Association, I hereby voluntarily apply to participate in the Physician Referral Service sponsored and operated by the Association. If accepted, I agree to abide by the following terms and conditions.

  1. I agree to abide by the Principles of medical Ethics of the Riverside County medical Association, the California Medical Association, and the American medical Association, as well as all applicable laws and regulations relating directly or indirectly to the practice of medicine.

  2. Participation is voluntary, and may be terminated by written notice to the Association.

  3. Upon notice of the filing of an accusation by the Medical Board of California against any participant, or in the event that any participant is charged with a crime substantially related to the qualifications, functions and duties of a physician, then each participant shall be automatically suspended from participation in the referral service. Suspension shall continue for a period of three years following satisfaction of any terms, conditions, or sanctions imposed, unless the participant is reinstated pursuant to paragraph "5" hereof.

  4. In the event of suspension, the Association will promptly give written notice thereof to the affected participant. Within ten days after the mailing of such notice, the participant may make written request for a hearing before the Association's Judicial Council.

  5. The Judicial Council shall consider the challenge of any participant contending that suspension is not appropriate, or is not warranted by the nature of the conduct or offense charges. Such hearing shall be conducted within thirty (30) days following receipt of written request, unless this period is extended for good cause. In the event that such disciplinary or criminal proceedings are finally decided in a manner adverse to any participant, with the imposition of terms or conditions of probation, the participant may seek reinstatement to the Referral Service prior to satisfaction of such terms and conditions by written request to the Judicial Council. A hearing upon such request shall be held within sixty (60) days after receipt thereof, and the Judicial Council shall determine whether there is good cause for such reinstatement.

  6. In addition to such automatic suspension, any participant may be summarily suspended from the referral panel by the Association's Board of Councilors, or the Executive Committee acting in its place, when there is substantial evidence that the participant may be impaired or unfit to discharge the responsibilities of a physician. In lieu of such summary suspension, limitations upon participation may be imposed. Written notice of summary suspension shall be given promptly, and shall specify the grounds of such action. The participant shall have the same rights of appeal to the Judicial Council afforded upon automatic suspension.

  7. The Board of Councilors may remove or suspend any participant from the referral panel, or impose restrictions upon the participant, upon its determination that the participant is unfit or has engaged in practices inconsistent with good medical practice or abusive of the physician-patient relationship. Prior to such action, the participant shall be afforded an informal conference with the Board or an Association Committee designed by the Board, which shall render its report to the Board. The participant shall be entitled to at least ten (10) days' prior written notice of such intended action, and may appeal to the Judicial Council within ten (10) days after the mailing of such notice, which shall specify the reasons for the Board's action. The Board's action shall be stayed pending the Judicial Council's final decision.

  8. A failure to attend any meeting ordered by this Association to inquire into any participant's fitness or qualifications for participation, or the failure to provide information reasonably related to such determination, shall be grounds for automatic suspension until such failure is cured.

  9. I agree that this agreement may be revised when appropriate, or when necessary to conform to applicable law. I understand and agree that my failure to sign and return to the Association a revised agreement within thirty (30) days after it is sent to me shall be deemed a withdrawal by me from participation in the Referral Service.

Signature:_____________________________________________Date:_________________

Printed/typed Name:__________________________________________________________

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