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Disclosure

Please provide a detailed explanation for any questions answered in the affirmative on a separate sheet

1. Has your professional license or registration ever been terminated, stipulated, restricted, limited, conditioned, suspended, revoked, voluntarily relinquished, or not renewed by any licensing board or any health related agency or a pending review?

Yes

2. Has your DEA registration ever been revoked, suspended, limited, or conditioned in any way or have you voluntarily relinquished your DEA registration, or a pending review?

Yes

3. Has your membership, participation, clinical privileges or employment ever been denied, Terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review organization, third party payer, clinic, hospital, medical staff or any health related agency or organization, or a pending review?

Yes

4. Have you ever voluntarily or involuntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professional license, or registration as an alternative to disciplinary action, or prior to or during an investigation into your professional conduct or competency?

Yes

5. Have you ever been reprimanded, censored, or otherwise disciplined by, or have you ever been subject to a corrective action agreement / plan by any licensing board, peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization?

Yes

6. Has your certificate or participation in any private, federal (i.e. Medicare, Medicaid, etc.) or state health insurance program ever been revoked or otherwise limited or restricted, or is any investigation or proceeding with respect to any such action presently underway?

Yes

7. Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, misdemeanor, or other offense involving fraud, misrepresentation, dishonesty, or deceit?

Yes

8. Have you ever been the subject or target of a sexual harassment complaint or investigation or other complaints or investigation involving sexual misconduct or impropriety?

Yes

9. Have you ever had any professional liability claims or lawsuits brought against you, including pending Claims or lawsuits, dismissed or dropped claims or lawsuits, settlements, or final judgements?

Yes

10. Has your professional liability carrier ever refused or canceled your coverage?

Yes

11. Have you ever been convicted of using illegal drugs?

Yes

12. Have you ever been convicted of driving under the influence?

Yes

As a condition of scheduling an interview with a Corazon client, we request that you to provide a copy of a self-query of the National Practitioner Data Base. Do you agree to provide this documentation?

Yes

Release of Information

I authorize Corazon to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, ethics, behavior or any matter reasonably having a bearing on my qualifications and authorize such third parties to release information.

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