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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and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn? If yes, please explain in the Comments section.

   
2. Has any information pertaining to you, including malpractice judgments and/or disciplinary action, ever been reported to the National Practitioner's Data Bank (NPDB) and/or any other practitioner data bank? If yes, please explain in the Comments section.

   
3. Have you, or any of your hospital or ambulatory surgery center privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed? If yes, please explain in the Comments section.

   
4. Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ambulatory surgery center privileges and/or your licenses? If yes, please explain in the Comments section.

   
5. Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation, in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs? If yes, please explain in the Comments section.

   
6. Have you been denied membership and/or been subject to probation, reprimand, sanction or disciplinary action, or have you been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g . hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO? If yes, please explain in the Comments section.

   
7. Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision? If yes, please explain in the Comments section.

   

By clicking on the 'Register' button below, I declare that I have personally examined this application and required attachments and, to the best of my knowledge, and belief, it is true, correct, and complete. I fully understand that any significant misstatements in, and omissions from, this application shall be cause for denial of membership or cause for dismissal from PennyDoc.com. I also authorize PennyDoc.com to collect, verify and maintain, information and copies of documents and records from professional licensing boards, hospitals, clinics and other entities, that support my current professional status. I also request and authorize every person, institution and professional licensing board of any state or country in which I hold or may have held a license to practice my profession, hospital, clinic, government agency (local,state, federal or foreign), law enforcement agency or other third parties and their representatives, to release information, records, transcripts and other documents, concerning my professional qualifications and competence, ethics, character and other information pertaining to me to PennyDoc.com.


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