Licensure
1  Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?

2 Have you ever received a reprimand or been fined by any state licensing board? 

Hospital Privileges and Other Affiliations
3 Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

4 Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?

5 Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?

Education, Training and Board Certification
6 Were you ever placed on probation, disciplined, formally reprimanded, suspended or aske d to resign during an internship, residency, fellowship, preceptorship or other clinical education progr am? If you are currently in a training program, have you been placed on probation, discipline d, formally reprimanded, suspended or asked to resign?

7 Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?

8 Have any of your board certifications or eligibility ever been revoked?

9 Have you ever chosen not to re-certify or voluntarily surrendered your board certificat ion(s) while
under investigation?

DEA or DPS
10 Have your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?

Medicare, Medicaid or other Governmental Program Participation
11 Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, s anctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare o r Medicaid program, or in regard to other federal or state governmental health care plans or programs?

Other Sanctions or Investigations
12 Are you currently or have you ever been the subject of an investigation by any hospita l, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare o r Medicaid program, or any other private, federal or state health program?

13 To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?

14 Have you ever received sanctions from or been the subject of investigation by any regulatory
agencies (e.g., CLIA, OSHA, etc.)?

Other Sanctions or Investigations
15 Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospita l,
facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital o r
healthcare facility of any military agency?

Malpractice Claims History
16 Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated)?


Criminal
17 Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is related to your qualifications, competence, functions, or duties as a medical professional

18 Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense?

19 Have you been court-martialed for actions related to your duties as a medical professional?

Ability to Perform Job
20 Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice dentistry or medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)

21 Do you use any chemical substances that would in any way impair or limit your ability to practice medicine or dentistry and perform the functions of your job with reasonable skill and safety?

22 Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?

23 Are you unable to perform the essential functions of a practitioner in your area of practice, with or
without reasonable accommodation?

PRE-APPLICATION
Full Name
Phone
Email
Date of Birth
Electronic Signature - type your full name
Explanation for YES answers
List all states where you have ever held a license with license numbers
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