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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and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn?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 Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation, in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs?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 Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in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.

   
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