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Thursday, O

ctober 31,

2024

Provider Disclosure Information

Name

David MARIA

david@fullspectrumaba.com

Phone Number

(813) 926-5454

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

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?

Yes

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)?

Yes

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?

Yes

4. Have you, or any en

tity, agent, owner, or

managing employee eve

r been denied enrollme

nt, suspended, exclude

d, terminated, or invo

luntarily withdrawn fr

om Medicare, Medicaid

or any other governmen

t or private healthcar

e or health insurance

program in any state?

Yes

5. Have you, or any entity, agent, owner, or managing employee ever had payments suspended by Medicare or Medicaid in any state?

Yes

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?

Yes

7. Have Medicare or Medicaid in any state ever taken recoupment actions against you, any entity, agent, owner, or managing employee?

Yes

8. Do you, or any entity, agent, owner, or managing employee owe money to Medicare or Medicaid that has not been paid in full?

Yes

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?

Yes

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?

Yes

11. Have you ever been

convicted under feder

al or state law of any

criminal offense rela

ting to fraud, theft,

embezzlement, breach o

f fiduciary responsibi

lity or other financia

l misconduct?

Yes

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?

Yes

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.

Yes

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?

Yes

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?

Yes

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?

Yes

17. Have you ever, whi

le under investigation

or to avoid an invest

igation, voluntarily w

ithdrawn or prematurel

y terminated your stat

us as a student or emp

loyee in any internshi

p, residency, fellowsh

ip, preceptorship, or

other clinical educati

on program?

Yes

18. Have any of your board certifications or eligibility ever been revoked?

Yes

19. Have you ever chosen not to re-certify or voluntarily surrendered your board certifications(s) while under investigation?

Yes

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?*

Yes

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

Yes

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)?

Yes

23. In the past ten ye

ars have you been conv

icted of, pled guilty

to, or pled nolo conte

ndere to any misdemean

or (excluding minor tr

affic violations)or be

en found liable or res

ponsible for any civil

offense that is reaso

nably related to your

qualifications, compet

ence, functions, or du

ties as a medical prof

essional, or for fraud

, an act of violence,

child abuse or a sexua

l offense or sexual mi

sconduct?*

Yes

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

Yes

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

Yes

26. Has your professional/general liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?

Yes

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?*

Yes

28. Are you currently or have you ever been subject to the terms of a Corporate Integrity Agreement (CIA)?

Yes

If yes, are you currently subject to the provisions of a Corporate Integrity Agreement?

Yes

Please add a detailed explanation for the questions that were answered with a YES.

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Signature