Health Care Professionals Credentialing & Business Data Gathering Form
Applicant Name:
Submit with all applications. Please answer the following questions to the best of your knowledge
with a “yes” or “no.” If you answer “yes” to any question(s) please complete Form A. Please make
copies of Form A as needed and complete one form for each “yes” answer.
1.
Has your license to practice in any jurisdiction ever been denied, restricted, limited,
suspended, revoked, canceled and/or subject to probation either voluntarily or
involuntarily, or has your application for a license ever been withdrawn? Yes No
2.
Have you ever been reprimanded and/or fined, been the subject of a complaint and/or
have you been notified in writing that you have been investigated as the possible
subject of a criminal, civil or disciplinary action by any state or federal agency which
licenses providers?
Yes No
3.
Have you lost any board certification(s), and/or failed to recertify? Yes No
4.
Have you been examined by a Certifying Board but failed to pass? Yes No
5.
Has any information pertaining to you, including malpractice judgments and/or
disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB)
and/or any other practitioner data bank? Yes No
6.
Has your federal DEA number and/or state controlled substances license been
restricted, limited, relinquished, suspended or revoked, either voluntarily or
involuntarily, and/or have you ever been notified in writing that you are being
investigated as the possible subject of a criminal or disciplinary action with respect to
your DEA or controlled substance registration? Yes No
7.
Have you, or any of your hospital or ambulatory surgery center privileges and/or
membership been denied, revoked, suspended, reduced, placed on probation,
proctored, placed under mandatory consultation or non-renewed? Yes No
8.
Have you voluntarily or involuntarily relinquished or failed to seek renewal of your
hospital or ambulatory surgery center privileges for any reason? Yes No
9 Have any disciplinary actions or proceedings been instituted against you and/or are
any disciplinary actions or proceedings now pending with respect to your hospital or
ambulatory surgery center privileges and/or your license? Yes No
10.
Have you ever been reprimanded, censured, excluded, suspended and/or disqualified
from participating, or voluntarily withdrawn to avoid an investigation, in Medicare,
Medicaid, CHAMPUS and/or any other governmental health-related programs? Yes No
11.
Have Medicare, Medicaid, CHAMPUS, PRO authorities and/or any other third party
payors brought charges against you for alleged inappropriate fees and/or quality-of-
care issues? Yes No
SECTION J. PROFESSIONAL HISTORY: CONFIDENTIAL
ADVERSE OR OTHER ACTIONS