Provider Disclosure Information 

  • Provider Disclosure Information 

  • Format: (000) 000-0000.
  • In what state will you be practicing?*

  • If you answer YES to any of the questions listed below, include a detailed explanation of each answer. 

  • 1. Do you have any pending misdemeanor or felony charges?*
  • 2. Have you ever been convicted of a felony?*
  • 3. Has your license to practice medicine in any jurisdiction ever been voluntarily or involuntarily denied, restricted, suspended, challenged, revoked, conditioned or otherwise limited?*
  • 4. In the past five years and up to and including the present, have you had any ongoing physical or mental impairment or condition which would make you unable, with or without reasonable accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform those essential functions without a direct threat to the health and safety of others?*
  • 5. Considering the essential functions of a practitioner in your area of practice is the past five years and up to and including the present, have you suffered from any communicable health condition that could pose a significant health and safety risk to your patients?*
  • 6. Have you ever been publicly reprimanded or disciplined by a professional licensing agency or board?*
  • 7. Has your DEA certification or state-controlled drug permit ever been restricted, suspended, revoked, voluntarily relinquished or otherwise limited?*
  • 8. Have any of your privileges or memberships at any hospital or institution ever been denied, suspended, reduced, revoked, not renewed, or otherwise limited?*
  • 9. Has your participation in Medicare, Medicaid, or any other government program ever been limited, curtailed or have you voluntarily excluded yourself from any of these programs?*
  • 10. Has your participation in an insurance company network ever been limited or terminated?*
  • 11. In the past five year and up to the present, have you had a history of chemical dependency or substance abuse that might affect your ability to competently and safely perform the essential functions of a practitioner in your area of practice?*
  • 12. In the past five years and up and including the present, have you had or do you have any mental or physical condition or do you take any medication that might affect the ability to competently and safely perform the essential functions of a practitioner in your area of practice?*
  • 13. Has any malpractice carrier ever made an out-of-court settlement or paid a judgement of a medical malpractice claim on your behalf or are any medical malpractice suits pending against you?*
  • 14. Has your professional liability insurer ever placed conditions or restrictions on your coverage to obtain coverage?*

  • Georgia Medicaid Disclosure:

  • 1. Have you ever been convicted of any criminal offense, had adjudication withheld on any criminal offense, pled no contest to any criminal offense or entered into a pre-trial agreement for any criminal offense?*
  • 2.Have you, or any entity, agent, owner, or managing employee ever had disciplinary action taken against any business or professional license held in this or any other state, including licenses issued by the Department of Community Health (GA DCH)?*
  • 3. Has your license to practice ever been restricted, reduced or revoked in this or any other state or been previously found by a licensing, certifying or professional standards board or agency to have violated the standards or conditions relating to licensure or certification or the quality of services provided, or entered into a Consent Order issued by a licensing, certifying or professional standards board or agency?*
  • 4. Have you, or any entity, agent, owner, or managing employee ever been denied enrollment, suspended, excluded, terminated, or involuntarily withdrawn from Medicare, Medicaid or any other government or private healthcare or health insurance program in any state?*
  • 5. Have you, or any entity, agent, owner, or managing employee ever had payments suspended by Medicare or Medicaid in any state?*
  • 6. Have you, or any entity, agent, owner, or managing employee ever had civil monetary penalties levied by Medicare, Medicaid or other State or Federal agency or program, including GA DCH, even if the fine(s) have been paid in full?*
  • 7. Have Medicare or Medicaid in any state ever taken recoupment actions against you, any entity, agent, owner, or managing employee?*
  • 8. Do you, or any entity, agent, owner, or managing employee owe money to Medicare or Medicaid that has not been paid in full?*
  • 9. Have you ever been convicted under federal or state law of a criminal offense related to the neglect or abuse of a patient in connection with the delivery of any health care goods or services?*
  • 10. Have you ever been convicted under federal or state law of a criminal offense relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance?*
  • 11. Have you ever been convicted under federal or state law of any criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct?*
  • 12. Have you, or any entity, agent, owner, or managing employee ever been found to have violated federal or state laws, rules or regulations in any program established under Medicare, Georgia's Medicaid program, any other state's Medicaid program, or Title XX, any other publicly funded federal or state health care, or health insurance program?*
  • 13. Are you NOT able to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation?  If you answer YES, you will be asked to describe why you are NOT able to perform.*
  • 14. 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?*
  • 15. Do you currently or did you in the last two years engage in the unlawful use of drugs, including the improper use of prescription drugs?*
  • 16. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you even been placed on probation, disciplined, formally reprimanded, suspended, or asked to resign?*
  • 17. Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?*
  • 18. Have any of your board certifications or eligibility ever been revoked?*
  • 19. Have you ever chosen not to re-certify or voluntarily surrendered your board certifications(s) while under investigation?*
  • 20. 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?**
  • 21. Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?*
  • 22. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?*
  • 23. 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?**
  • 24. Have you ever been court-martialed for actions related to your duties as a medical professional?*
  • 25. Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?*
  • 26. Has your professional/general liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?*
  • 27. Have you ever been assessed a surcharge, or rated in ahigh-risk class for your specialty, by your professional/general liability insurance carrier, based on your individual liability history?**
  • 28. Are you currently or have you ever been subject to the terms of a Corporate Integrity Agreement (CIA)?*
  • If yes, are you currently subject to the provisions of a Corporate Integrity Agreement?*
  • Should be Empty: