Sanctions If any question below is responded to with a please provide an explanation on a separate sheet, and “yes”, submit back with the credentialing application. Have there been or are there currently pending any malpractice claims, suits, Yes No settlements or proceedings involving the facility? Has the facility ever been disciplined, fined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard Yes No to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Has the facility ever voluntarily relinquished or withdrawn, or failed to proceed with an application in order to avoid an adverse action, or to preclude an Yes No investigation or while under investigation relating to professional conduct? Has the facility ever been subjected to sanctions by a Professional Review Organization (PSRO or PRO), a Third Party Payer, or a Regulatory Agency (CLIA, Yes No OSHA, etc.) Has the facility’s DEA Registration or Controlled Substance Certificate (if Yes No applicable) ever been denied, suspended, or revoked for any reason? Has an officer ever been convicted of, pled guilty to, or pled nolo contendere to Yes No any felony including an act of violence, child abuse or a sexual offense? Has the corporation, an officer or a board member ever been convicted of a Yes No felony? CMS Required Disclosure Statement Name of Entity / Individual EIN / SSN NPI Taxonomy Address/Street City/State/Zip
Sanctions If any question below is responded to with a “yes”, please provide an explanation on a separate sheet, and submit back with the credentialing application. Have there been or are there currently pending any malpractice claims, suits, settlements or proceedings involving the facility? Yes No Has the facility ever been disciplined, fined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes No Has the facility ever voluntarily relinquished or withdrawn, or failed to proceed with an application in order to avoid an adverse action, or to preclude an investigation or while under investigation relating to professional conduct? Yes No Has the facility ever been subjected to sanctions by a Professional Review Organization (PSRO or PRO), a Third Party Payer, or a Regulatory Agency (CLIA, OSHA, etc.) Yes No Has the facility’s DEA Registration or Controlled Substance Certificate (if applicable) ever been denied, suspended, or revoked for any reason? Yes No Has an officer ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense? Yes No Has the corporation, an officer or a board member ever been convicted of a felony? Yes No CMS Required Disclosure Statement Name of Entity / Individual EIN / SSN NPI Taxonomy Address/Street City/State/Zip
Cenpatico%20IC%20Organizational%20Credentialing%20Application-UPDATED%202-16-17.docx