First Name*
Last Name*
Email Address*
Phone*
Have your privileges at any institution been limited, restricted or revoked?*
If you answered 'YES' to the previous question, please explain below...
Has your narcotics registration been suspended or revoked?*
If you answered 'YES' to the previous question, please explain below...
Have you been denied membership, renewal or has disciplinary action been instituted against you in any professional organization (i.e. medical, dental, or hygiene)?*
If you answered 'YES' to the previous question, please explain below...
Have you been a defendant or subject of a malpractice action?*
If you answered 'YES' to the previous question, please explain below...
Do you have, or are you subject to any pending actions by The New York State Department of Education, Department of Professional Discipline or any other state in which you may hold (or have held) a professional license?*
If you answered 'YES' to the previous question, please explain below...
Have you ever been denied or had you medical malpractice revoked, non-renewed, limited or terminated?*
If you answered 'YES' to the previous question, please explain below...
Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal or state health insurance program?*
If you answered 'YES' to the previous question, please explain below...
Have you ever been investigated or censured for violation of patient's rights?*
If you answered 'YES' to the previous question, please explain below...
Do you have any impairment (mental or physical) that may interfere with the performance of your duties?*
If you answered 'YES' to the previous question, please explain below...