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SR NO.
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ATTRIBUTES
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YES | NO | N/A
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1
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Has your medical license in any state ever been investigated, reprimanded, limited, denied, suspended, revoked, or surrendered, or have you ever received disciplinary or administrative actions of any kind on any license?
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YesNoN/A
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2
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Have your privileges at any hospital ever been investigated, suspended, limited or revoked, even if they were subsequently reinstated?
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YesNoN/A
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3
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During your medical education and training programs, were you ever put on academic or clinical probation, asked to repeat a rotation, had your privileges investigated, reprimanded, limited, denied, suspended, revoked, or were you subject to any disciplinary action of any kind?
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YesNoN/A
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4
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Have you ever been denied membership or renewal thereof or been subject to disciplinary action by any medical organization?
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YesNoN/A
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5
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Have you ever been involved, directly or indirectly, in a claim, potential claim or suit arising out of the rendering or failing to render professional services, even if the suit was subsequently dropped or dismissed?
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YesNoN/A
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6
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Do you currently have any potential claims or suits, or are you aware of any claims or suits pending, rising from the rendering or failing to render of professional services?
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YesNoN/A
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7
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Has your professional liability insurance ever been denied, canceled or renewal refused?
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YesNoN/A
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8
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Has your DEA certificate ever been investigated, limited, denied, canceled, or renewal refused?
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YesNoN/A
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9
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Have you ever been charged with or convicted of a felony or a misdemeanor, pleaded “nolo contender” or have you ever been placed on probation for any offense other than a traffic violation, including any charges that were dropped or reduced?
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YesNoN/A
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10
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Has your participation in any private, federal, or state health agency or insurance program ever been investigated, limited, suspended, sanctioned or otherwise restricted, even if it was a voluntary opt-out?
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YesNoN/A
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11
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Have you ever been addicted to a controlled substance that has affected your ability to perform the duties of a physician?
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YesNoN/A
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