Clinician Applicants Only Employee Attestation Release, and Signature Pages

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Please answer Each question below. Failure to answer a question may delay the processing of your application. IF YOU ANWER "YES" TO ANY QUESTION BELOW, PLEASE PROVIDE A FULL EXPLANATION OF YOUR INVOLVEMENT, DATE(S) OF ACTION, STATUS/OUTCOME, AMOUNT OF JUDGEMENT/SETTLEMENT, AND DETAILS OF ANY ADVERSE DECISIONS. PLEASE ANSWER "NO" TO ANY QUESTION YOU FIND NOT APPLICABLE. Also, include a copy of any order or settlement ofr each proceeding. If a case is pending, please provide a letter from your attorney describing the status case.

First Name

Last Name

Have any malpractice suits, arbitration or other proceeding ever been initiated against you? if " Yes" provide an explanation of your involvement for each action, include the date each action began, status/outcome, amount of judgment/ setlment and adverse decision.

Other than items identified in question #1, are there any past or current pending legal actions against you or your professional organization?

Do you have any physical or mental condition, treated or untreated which, in any way, impairs your ability to paractice to the fullest extent of your license and qualifications, or in any way poses a risk of harm to consumers?

Does your use of alcohol or chemical substances in any way impair or limit your ability to practice your profession which reasonable skill and saftey?

Are you currently engaged in illegal use or abuse of controlled substances?

Have you ever had a clinical license/ certification encumberred, suspended, revoked, reduced, denied, or voluntarily surrended?

Has disciplinary action by any clinical licensing/certification body or Professional Conduct board ever been intiated against you?

Have your hospital privileges ever been suspended, revoked, denied, or voluntarily suspended?

Has your malparactice insurance ever been canceled?

Have you ever been charged or convicted of a feloney in any state?

Has your DEA certificate ever been suspended or otherwise limited?

Have you ever been removed, sanctioned or suspended from membership in a managed care network, professional assosiation and/or behavioral health organization?

To your knowledge, has information pretaining to you ever been reported to the National practitioner data Bank, H.I.I.P.A HEALTH CARE registry or Health care integrity & Protection data Bank?

Have you ever been reprimended, censured, excluded, suspended or discualified by the medicare or madical programs?