California Participating Physician Application - 05/97 Page 8 of 10
XVI. ATTESTATION QUESTIONS
Please answer the following questions "yes" or "no." If your answer to questions A through K is "yes," or if your answer to L is “no,” please provide
full details on separate sheet.
A. Has your license to practice medicine in any jurisdiction, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any
jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily
relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of
reprimand or is such action pending?
B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you
voluntarily or involuntarily relinquished eligibility to provide services or accepted conditions on your eligibility to provide services, for reasons relating to possible
incompetence or improper professional conduct, or breach of contract or program conditions, by Medicare, Medicaid, or any public program, or is any such action
C. Have your clinical privileges, membership, contractual participation or employment by any medical organization (e.g. hospital medical staff, medical group,
independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those
that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system), ever been
denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach
of contract, or is any such action pending?
D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual
participation or employment, or resigned from any medical organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health
plan, health maintenance organization (HMO), preferred provider organization (PPO), medical society, professional association, medical school faculty position or
other health delivery entity or system) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for
such an investigation not being conducted, or is any such action pending?
E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship,
residency, fellowship, preceptorship, or other clinical education program?
F. Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced,
limited, subjected to probationary conditions, or not renewed , or is any such action pending?
G. Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing
from eligible to certified)?
H. Have you ever been convicted of any crime (other than a minor traffic violation)?
I. Do you presently use any drugs illegally?
J. Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases, or are there any
filed and served professional liability lawsuits/arbitrations against you pending?
K. 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, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew,
or limit your professional liability insurance or its coverage of any procedures?
L. Are you able to perform all the services required by your agreement with, or the professional staff bylaws of, the Healthcare Organization to which you are
applying, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of
I hereby affirm that the information submitted in this Section XVI, Attestation Questions, and any addenda thereto is true, current, correct, and complete to the best
of my knowledge and belief and is furnished in good faith. I understand that material, omissions or misrepresentations may result in denial of my application or
termination of my privileges, employment or physician participation agreement.
Print Name Here:
(Stamped Signature Is Not Acceptable)