Attestation - Cognitive Organics

Name *

First

Last

Questions

Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? *

Yes
No

Have any of your board certifications ever been suspended, revoked, or voluntarily surrendered? *

Yes
No

Have your privileges at any hospital, facility, HMO, or health plan been voluntarily or involuntarily surrendered, denied, suspended, revoked, restricted, limited, or placed on probation? *

Yes
No

Have you ever been placed on probation or asked to resign from an internship, residency or other training program? *

Yes
No

Has your malpractice insurance ever been canceled, suspended, restricted, limited, special rated, or not renewed? *

Yes
No

Has information pertaining to you ever been reported to the National Practitioner Data Bank? *

Yes
No

Have you ever been indicted or convicted of a criminal offense related to the involvement in such programs established by Titles XVIII, XIX, or XX? *

Yes
No

Have you as the Provider ever been indicted or convicted of a violation of State or Federal Law? *

Yes
No

Have you been indicted or convicted of a criminal offense related to the involvement of such persons. or organizations in any of the programs established by Titles XVIII, XIX, or XX? *

Yes
No

Have you been sanctioned by the Medicare Program or any state Medicaid program within the past ten years? *

Yes
No

involuntarily a any

Has there been any final adverse action including: a Medicare-imposed revocation of any Medicare billing privileges; suspension or revocation of a license to provide health care by any State licensing authority; revocation or suspension by an accreditation organization; a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years; or an exclusion or debarment from participation in a Federal or State health care program. *

Yes
No

Has your license, registration or certification to practice in your profession, ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board? *

Yes
No

Has there been any challenge to your licensure, registration or certification? *

Yes
No

Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board? *

Yes
No

Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? *

Yes
No

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? *

Yes
No

Have you ever been court-martialed for actions related to your duties as a medical professional? *

Yes
No

In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? *

Yes
No

Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? *

Yes
No

Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.) *

Yes
No

Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation? *

Yes
No

Explain any Yes answers

Signature *

Clear Signature