{"content":[{"text":"General Attestation Form \n Please answer yes or no to each of the following questions. If there is a yes \n response, please describe the circumstances on a separate sheet of paper. \n Indicate N/A for any question that does not apply. Please note that answering \n yes to any question does not necessarily disqualify you from participation in the \n ACBN. The information is sought as part of the overall credentialing process.","bbox":{"left":0.147059,"top":0.132599,"width":0.7058980000000001,"height":0.123976}},{"text":"Yes __ No__ Prior malpractice or civil judgments or settlements? \n Yes __ No__ Pending personal or professional claims? \n Yes __ No__ Has your professional liability insurance ever been cancelled or \n renewal refused? \n Yes __ No__ Have you ever been denied a request for hospital privileges, or \n have your privileges ever been voluntarily or involuntarily revoked, suspended or \n terminated? \n Yes __ No__ Has your license to practice in any state or country ever been \n revoked, suspended, or otherwise, limited (whether or not such revocation, \n suspension or limitation was stayed)? \n Yes __ No__ Has any disciplinary action(s), investigation(s), ever been initiated \n or are any pending against you by a state or federal agency? \n Yes __No__ Have you ever been censured, reprimanded, excluded, \n suspended, or disqualified by the Medicare or Medicare programs? \n Yes __No__ Have you ever been convicted of, or pleaded no contest to, any \n criminal charges brought against you? \n Yes __No__ Do you currently use drugs or alcohol to the point that it might \n affect your ability to practice or place your patients at increased risk? \n Yes __No__ Have you ever been refused or suspended from a state or federal \n program? \n Yes __ No__ Have you had any licensing authority or regulatory agency actions \n e.g. probation, administrative warning, suspension, fines, etc.? \n Yes __No__ Do you or any member of your family have ownership or other \n financial interest in any business which provides ancillary health services, \n equipment, pharmaceuticals, laboratory services, or supplies to which you do, or \n will refer health care business? \n Yes __No__ During the past five (5) years, from date of occurrence, filing or \n resolution, with or without monetary settlement, have you had any malpractice \n suits or proceedings related to your practice? Please describe each case. \n Yes __No__ During the past five (5) years has your malpractice insurance ever \n been cancelled, not renewed or has your malpractice risk pool been cancelled?","bbox":{"left":0.147058,"top":0.270606,"width":0.706004,"height":0.543466}},{"text":"___________________________________________ _____________________ \n Signature Date","bbox":{"left":0.147059,"top":0.845527,"width":0.7031320000000001,"height":0.038242}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}