Oregon Practitioner Credentialing Application
Page 11 of 12 INITIALS: ____________DATE: _____________________________
– This section to be completed by the Practitioner.
Modification to the wording or format of these Attestation Questions will invalidate the application.
Please answer the following questions “yes” or “no”. If your answer to any of the following questions is “yes”, please provide details
and reasons, as specified in each question, on a separate sheet. Please sign and date each additional sheet.
Has your license, certification, or registration to practice your profession, Drug Enforcement Administration (DEA)
registration, or narcotic registration/certificate in any jurisdiction ever been denied, limited, suspended, revoked, not
renewed, voluntarily or involuntarily relinquished, or subject to stipulated or probationary conditions, had a corrective
action, or have you ever been fined or received a letter of reprimand or is any such action pending or under review?
Have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded for any reasons, by
Medicare, Medicaid, or any public program or is any such action pending or under review?
Have you ever been denied clinical privileges, membership, or contractual participation by any health care related
or have clinical privileges, membership, participation or employment at any such organization ever
been placed on probation, suspended, restricted, revoked, voluntarily or involuntarily relinquished or not renewed, or
is any such action pending or under review?
Have you ever surrendered clinical privileges, accepted restrictions on privileges, terminated contractual participation
or employment, taken a leave of absence, committed to retraining, or resigned from any health care related
while under investigation or potential review?
Has an application for clinical privileges, appointment, membership, employment or participation in any health care
related organization* ever been withdrawn on your request prior to the organization’s final action?
Has your membership or fellowship in any local, county, state, regional, national, or international professional
organization ever been revoked, denied, limited, voluntarily or involuntarily relinquished or not renewed, or is any
such action pending or under review?
voluntarily or involuntarily left or been discharged from medical school or subsequent training
Have you ever had board certification revoked?
Have you ever been the subject of any reports to a state or federal data bank or state licensing or disciplinary entity?
Have you ever been charged with a criminal violation (felony or misdemeanor)?
Do you presently use any illegal drugs?
Do you now have, or have you had, any physical condition, mental health condition, or chemical dependency condition
(alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice, with or without
reasonable accommodation, the privileges requested?
If reasonable accommodation is required, please specify the accommodation(s) required on a separate sheet.
Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner
agreement/hospital appointment, with or without reasonable accommodation, according to accepted standards of
Have any professional liability claims or lawsuits ever been closed and/or filed against you?
If yes, please complete
ofessional Liability Action Detail,
past or current claim and/or
Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced
limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance?
*e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO),
preferred provider organization (PPO), physician hospital organization (PHO), medical society, professional association, health care faculty
position or other health delivery entity or system
I certify the information in this entire application is complete, current, correct, and not misleading. I understand and acknowledge that any
misstatements in, or omissions from this application will constitute cause for denial of my application or summary dismissal or termination of my
clinical privileges, membership or practitioner participation agreement. A photocopy of this application, including this attestation, the authorization
and release and any or all attachments has the same force and effect as the original. I have reviewed this information on the most recent date indicated
below and it continues to be true and complete. While this application is being processed, I agree to update the information originally provided in this
application should there be any change in the information.
I agree to provide continuous care for my patients, until the practitioner/patient relationship has been properly terminated by either party, or in
accordance with contract provisions.