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Medical Professionals Questionnaire
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
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State
ZIP Code
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)?
(Required)
Yes
No
2. Are there any now still pending?
(Required)
Yes
No
3. Has any judgement, payment of claim, or settlement ever been made against you in any professional liability cases?
(Required)
Yes
No
4. Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?
(Required)
Yes
No
5. Have you ever been denied professional insurance or has your policy ever been cancelled?
(Required)
Yes
No
More information about your liability claims:
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and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn?
(Required)
Yes
No
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?
(Required)
Yes
No
3. Have you lost any board certification(s), and/or failed to rectify?
(Required)
Yes
No
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?
(Required)
Yes
No
N/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?
(Required)
Yes
No
N/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?
(Required)
Yes
No
N/A
7. Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ambulatory surgery center privileges for any reason?
(Required)
Yes
No
N/A
8. Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending?
(Required)
Yes
No
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?
(Required)
Yes
No
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?
(Required)
Yes
No
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?
(Required)
Yes
No
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?
(Required)
Yes
No
More information about your professional sanctions:
Health Status
1. 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?
(Required)
Yes
No
2. Are you unable to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodations?
(Required)
Yes
No
More information about your health status:
Chemical, Substance or Alcohol Abuse
1. Are you currently engaged in illegal use of any legal or illegal substances?
(Required)
Yes
No
2. 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?
(Required)
Yes
No
More information about substance abuse:
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.
Consent
Date
Please list any professional societies you're a part of or any fellowships awarded to you (ACOG, AAPLOG, etc.):
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