I attest that none of the following areas have been or are currently in the process of being reviewed, investigated, sanctioned, restricted, denied, revoked, suspended, reduced, limited, placed on or pending probation, placed on or pending disciplinary action, not renewed, challenged, voluntarily or involuntarily relinquished

1. Medical license in any State or Country

2. Other Professional Registration or Certification

3. DEA / Controlled Substance Registration

4. Membership / Privileges on any hospital Medical Staff or out-patient facility

5. Membership in a Medical or Professional Organization / Society

6. Academic or Professional Appointment

7. Other Institutional Affiliation or Status

8. Private, Federal, or State health insurance program (including Medicare, Medical)

9. Individual focused review required by PRO or similar review agency

10. Federal (e.g. Branch of US Military, the Veteran’s Administration or the US Public Health System)

11. Voluntarily or involuntarily relinquished any privileges at any facility

12. Judgments for settlements made or pending against you in proessional liability cases

13. Exclusion of any specific procedures from coverage by your professional liability insurance carrier

14. Charged with or convicted of a misdemeanor or (other than minor traffic offenses)

I agree that the discovery of misrepresentation, misstatement, or omission after being granted access to this platform shall be cause for revocation of access.