| 11. PROVIDER PROFILE |
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| A. Please answer all provider profile questions. |
| NOTE: If "yes" is checked, please explain fully in the space provided. |
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Yes No |
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| 1. |
Health Status: Do you have any physical, mental, or emotional condition, including but not limited to any history of drug or alcohol abuse, which currently impairs your ability to render the professional services which are the subject of this application? "Currently" means recently enough so that the condition could reasonably have an impact on your ability to safely and competently render the professional services, which are the subject of this application. |
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| 2. |
Insurance Coverage: Has your professional liability insurance coverage ever been denied, canceled, or non-renewed or initially refused upon application? |
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| 3. |
License: Has your medical or professional license in any state ever been revoked, suspended, placed on probation, conditional status, or limited? |
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a. Have you ever voluntarily surrendered your license? |
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b. Are formal charges pending against you at this time? |
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DEA: Has your DEA Registration Certificate ever been suspended, revoked, subjected to probation, placed on conditional status, or limited? |
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| 5. |
Hospital Privileges: Has any hospital ever dismissed you from its staff? |
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a. Has any hospital ever revoked, suspended, or limited your privileges? |
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b. Has any hospital initiated either type of the aforementioned action by formal notice to you? |
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c. Has any hospital refused or denied you privileges? |
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d. Have you ever voluntarily surrendered your hospital privileges? |
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Hospital Sanctions: Have you ever surrendered your clinical privileges upon threat of censure, restriction, suspension or revocation of such privileges? |
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Professional Membership(s): Has your membership in any professional society or association ever been canceled, revoked, or censured? |
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Medicare/Medicaid/TRICARE: Have you ever been fined, had an arrangement suspended, been expelled from participation or had criminal charges brought against you by any Medicare, Medicaid or TRICARE program? |
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| 9. |
Criminal Offenses: Have you ever been arrested, charged with or convicted of a felony or involved in charges relating to moral or ethical turpitude, including crimes with children? |
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a. Have you ever been named as a defendant in any criminal proceeding? |
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| 10. |
Board Discipline: Have you ever been the subject of disciplinary proceedings by any professional association or organization (i.e., state licensing board; county, state or national professional society; hospital medical or clinical staff)? |
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| 11. |
Malpractice Action: Has any malpractice action against you been brought or settled in the past 5 years or has there been any unfavorable judgment(s) against you in a malpractice action? |
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a. To your knowledge, is any malpractice action against you currently pending? |
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b. If your answer to question 11 above is yes, please mark the number of malpractice claims pending and/or closed: |
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One Two More than 2(please give number) |
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c. Have you ever been a defendant in any lawsuit involving your practice where there has been an award or payment of $100,000 or more? |
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d. Have you had any malpractice claims where there has been an award or payment of $100,000 or more? |
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| 12. |
Comments: If you answered yes to any of the above questions, please explain fully in this space. |
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