1. Have you ever had any professional liability actions (pending, settles, arbitrated, mediated, or litigated), been reprimanded or otherwise sanctioned by any licensure agency, or asked to surrender your license in any state? If yes, please provide information.

    2. Have you ever been placed on probation or remediation, disciplined, formally reprimanded, suspended or asked to resign during internship, residency, fellowship training, any clinical education or research program or left before you completed your contracted time? If yes, please provide information.

    3. Are you in the process or have you ever had your employment or other relationship with a hospital, healthcare facility, educational program, research program, pharmaceutical company or your participation with a managed care organization voluntarily or involuntarily relinquished, denied, revoked, terminated, suspended, reduced, limited, or placed on probation, not renewed, modified or have there been an investigation into any of the above? If yes, provide information.

    4. Have you ever been the subject of an investigation by an agency or been suspended, sanctioned, excluded, or otherwise restricted or precluded from participating in Medicare, Medicaid, or an other federal, state, or private health insurance program? If yes, provide information.

    5. Have you ever withdrawn or failed to proceed with an application for licensure or have any application for licensure pending? If yes, provide information.

    6. Are you authorized to work in the United States?

    This form uses Akismet to reduce spam. Learn how your data is processed.