I attest that none of the following areas have been or are currently in the process of being reviewed, investigated, sanctioned, restricted, denied, revoked, suspended, reduced, limited, placed on, or pending probation, placed on, or pending disciplinary action, not renewed, challenged, voluntarily or involuntarily relinquished
Medical license in any State or Country
Other Professional Registration or Certification
DEA / Controlled Substance Registration
Membership / Privileges on any hospital Medical Staff or out-patient facility
Membership in a Medical or Professional Organization / Society
Academic or Professional Appointment
Other Institutional Affiliation or Status
Private, Federal, or State health insurance program (including Medicare, Medical)
Individual focused review required by PRO or similar review agency
Federal (e.g. Branch of US Military, the Veteran’s Administration or the US Public Health System)
Voluntarily or involuntarily relinquished any privileges at any facility
Judgments for settlements made or pending against you in professional liability cases
Exclusion of any specific procedures from coverage by your professional liability insurance carrier
Charged with or convicted of a misdemeanor or (other than minor traffic offenses)
I agree that the discovery of misrepresentation, misstatement, or omission after being granted access to this platform shall be cause for revocation of access.
I agree that the discovery of misrepresentation, misstatement, or omission after being granted access to this platform shall be cause for revocation of access.
