Preceptor Contact Form
Preceptors are an integral part of Rocky Vista University as they give our students hands-on training in the real world with real patients.
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Date of Birth
I have read and acknowledged the RVU Title IX policy.
If other, please explain:
Does this practice offer TeleMedicine?
Practice Zip Code
Degree Earned (i.e. - DO, MD, PA, ANP, etc.)
Are you certified?
Certification Type (ABFM, FACOFP, etc.):
Certification Expiration Date
Please attach your certification (.docx, .pdf):
If you have issues submitting the form, please remove any commas, spaces, or other special characters from the file, re-upload, and contact us if you are still experiencing problems.
Please explain your reasoning for application without board certification.
Certification Type (ABFM, FACOFP, etc.)
Please explain how you are board eligible:
Certification File - SUSAN ONLY
Licensure Type (e.g. Medical)
Licensure Expiration Date
List the hospital(s) used in your clinical practice (to ensure we have appropriate Affiliation Agreements):
Have you had any prior experience precepting/teaching medical students, residents, fellows, nurses, nurse practioners, physician assistants, or EMTs?
Students Accepted for Rotation (REQUIRED):
Would you like an Adjunct Clinical Faculty Appointment from Rocky Vista University?
Please attach your CV below (.docx, .pdf):
Please attach your Certificate of Insurance (COI) below (.docx, .pdf):
COI Expiration Date:
Would you like online access to the Frank Ritchel Ames Memorial Library at Rocky Vista University?
Name of RVU Clinical Coordinator or Student you are working with (if applicable)
If this form is being submitted on behalf of the preceptor, who is submitting this form?
Please double check that you have uploaded all required files before clicking the Submit button.
If you have any questions, please contact Preceptor Staff Services in the Clinical Education Department at firstname.lastname@example.org
For Dr. Miller
Notes for Dr. Miller:
Credentialing or Denial Notes