Medical Professionals Questionnaire First Name: Last Name: Address: City: State: Phone Number: Alternate Phone Number: Zip code: Your email Date of Birth: Active License Number(s): PROFESSIONAL LIABILITY/CLAIMS 1. Have any professional liability lawsuits been filed against you during the past ten years (including those closed)? YesNo 2. Are there any now still pending? YesNo 3. Has any judgement, payment of claim, or settlement ever been made against you in any professional liability cases? YesNo 4. Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage? YesNo 5. Have you ever been denied professional insurance or has your policy ever been cancelled? YesNo PROFESSIONAL SANCTIONS 1. Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, canceled, and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn? YesNo 2. Have you ever been reprimanded and/or fired, been the subject of a complaint, and/or have you been notified in writing that you have been investigated as the possible subject of a criminal, civil, or disciplinary action by any state or federal agency that licenses providers? YesNo 3. Have you lost any board certification(s), and/or failed to rectify? YesNo 4. Has any information pertaining to you, including malpractice judgements and/or disciplinary actions ever been reported to the National Practitioner Data Bank (NPDB) or any other practitioner data bank? YesNoN/A 5. Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended, or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to you DEA or controlled substance registration? YesNoN/A 6. Have you, or any of your hospital or ambulatory surgery center privileges and/or memberships been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation, or non-renewed? YesNoN/A 7. Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ambulatory surgery center privileges for any reason? YesNoN/A 8. Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending? YesNo 9. Have you ever been reprimanded, censured, excluded, suspended, and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation, in Medicare, Medicaid, CHAMOUS, and/or any other government health-related programs? YesNo 10. Have Medicare, Medicaid, CHAMPUS, PRO authorities, and/or any other third-party payers brought charges against you for alleged inappropriate fees and/or quality-of-care issues? YesNo 11. Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other state or country and/or do you have any criminal charges pending other than minor traffic offenses in this state or any other state or country? YesNo 12. you been the subject of a civil or criminal or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal, or administrative action regarding sexual misconduct, child abuse, domestic violence, or elder abuse? YesNo HEALTH STATUS 13. Do you have a medical condition, physical defect, or emotional impairment which in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety? YesNo 14. Are you unable to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodations? YesNo CHEMICAL SUBSTANCE OR ALCOHOL ABUSE 15. Are you currently engaged in illegal use of any legal or illegal substances? YesNo 16. 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? YesNo ACCEPTANCE: I hereby acknowledge and represent that I have read and am familiar with the national, state, and local principles, standards, and ethics including laws and regulations that apply to and govern my specialty and/or profession, which are the governing standards of care. I agree to notify Caring Network of any circumstances that would change my status in licensure, DEA, liability insurance coverage, board certification status, or hospital privileges. Typing your full name below signifies that you are completing this form with an electronic signature. Date: Please list any professional societies you're a part of or any fellowships awarded to you (ACOG, AAPLOG, etc.):