HEALIA DIGITAL

Provider Information Release

Provider Information Release


I attest that none of the following areas have been or are currently in the process of being reviewed, investigated, sanctioned, restricted, denied, revoked, suspended, reduced, limited, placed on, or pending probation, placed on, or pending disciplinary action, not renewed, challenged, voluntarily or involuntarily relinquished

Medical license in any State or Country

Other Professional Registration or Certification

DEA / Controlled Substance Registration

Membership / Privileges on any hospital Medical Staff or out-patient facility

Membership in a Medical or Professional Organization / Society

Academic or Professional Appointment

Other Institutional Affiliation or Status

Private, Federal, or State health insurance program (including Medicare, Medical)

Individual focused review required by PRO or similar review agency

Federal (e.g. Branch of US Military, the Veteran’s Administration or the US Public Health System)

Voluntarily or involuntarily relinquished any privileges at any facility

Judgments for settlements made or pending against you in professional liability cases

Exclusion of any specific procedures from coverage by your professional liability insurance carrier

Charged with or convicted of a misdemeanor or (other than minor traffic offenses)

I agree that the discovery of misrepresentation, misstatement, or omission after being granted access to this platform shall be cause for revocation of access.

I agree that the discovery of misrepresentation, misstatement, or omission after being granted access to this platform shall be cause for revocation of access.