Dental Job Opportunity Form - Colorado Rural Health Center

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CPR: Dental Job Opportunity Form

1. EMPLOYER CONTACT INFORMATION
Practice Site Name*
Hospital or Parent Organization Name (if different)
Practice Site Address*
Street Address Address Line 2 City State ZIP Code
Recruitment Contact's Name*
Title*
Phone*
Email*
2. BENEFITS OFFERED
Medical*
- Yes
- No
Dental*
- Yes
- No
Vision*
- Yes
- No
PTO*
- Yes
- No
If PTO is offered, please describe.
Holidays*
- Yes
- No
If Holidays are offered, please describe.
401k*
- Yes
- No
CME Allowance*
- Yes
- No
If CME allowance offered, days off and amount offered?
Relocation assistance*
- Yes
- No
If relocation assistance offered, amount offered?
Malpractice covered*
- Yes
- No
Loan repayment through practice (other than federal, state programs)
- Yes
- No
Professional fees paid by practice*
- Yes
- No
If professional fees paid by practice, please describe.
If other benefits offered, please specify.
3. POSITION DETAILS
1. What type of provider(s) are you recruiting?*
- Dentist
- Dental Hygienist
2. How many are needed?*
Please enter a number greater than or equal to 0.
3. Why is the position open?*
4. Hire date:*
MM slash DD slash YYYY
5. Open to students/residents graduating in 2017?*
- Yes
- No
6. Will you consider J-1 Visa/H1-B candidates?
- Yes
- No
7. Full-time/Part-time:
If hiring for full-time, will you consider:
- Part-time
- Temporary
- Neither
8. Weekly Schedule - Days and Hours
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
9. After hours call schedule:*
10. Experience required:*
- Yes
- No
11. Salary Range:*
How salary is determined (guaranteed salary, daily rate, production, collections, RVUs, etc.)*
12. Specialist on staff?*
- Yes
- No
If so, what type of specialty and how often?
13. General dentist to perform specialty services?*
- Yes
- No
If so, what specialty services?
14. How many dental assistants will work with the hired provider?
Please enter a number greater than or equal to 0.
15. Does the dental hygienist run an accelerated schedule?
- Yes
- No
If yes, please include information about satellite clinics:
Scope of Practice (Duties and Responsibilities):*
4. EMPLOYER DETAILS
1. What type of employer is hiring?*
- Rural hospital
- Rural, hospital-based clinic
- Rural, private practice
- Rural or urban Community Health Center (CHC)
- Rural or urban safety-net clinic
2. What is the name of the practice that the provider will primarily work at?*
3. Number of dentists at practice:
Please enter a number greater than or equal to 0.
4. Number of dental hygienists at practice:
Please enter a number greater than or equal to 0.
5. Number of dental assistants at practice:*
Please enter a number greater than or equal to 0.
6. Are dentists employed by practice or independent contractors?
7. Does the practice accept Medicare/Medicaid patients?*
- Yes
- No
8. Does the practice accept uninsured patients?*
- Yes
- No
9. Does the practice utilize a sliding fee scale for low income and uninsured patients?*
- Yes
- No
10. Is the practice designated as a HPSA?
- Yes
- No
10. Is the practice a non-profit facility?
- Yes
- No
HPSA Score (if designated):
11. Information about the hospital or nearest hospital:
a. Name of the hospital:
b. Number of beds:
c. Distance to the hospital:
d. Hospital services:
Practice Description*
(Please give us a "sense" of what the provider's day to day practice would be like.)
If there is any other information you would like us to use when writing your job description, please attach it here:
Drop files here or

Accepted file types: doc, txt, pdf, Max. file size: 50 MB.

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Colorado Rural Health Center
6551 South Revere Parkway
Suite 155
Centennial, CO 80111

Email: info@coruralhealth.org
Phone: 303.832.7493 or 800.851.6782

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