D7_PROVIDER_CERTIFICATION.pdf

RFP 17-242-SOL-00085

CERTIFICATION

I graduated from the _______________________________ located in _______________

(Name of educational institution) (City/State)

_______________________. In the year of ____________________ and was awarded a degree/Certificate in ___________________________.

(nursing, medicine, etc.)

I ( ) did ( ) did not graduate from a foreign university. If yes, I passed the

( ) FLEX or ( ) ECFMG exam on _________________.

(date)

My license to practice ( ) has ( ) has not been terminated, suspended, or revoked in any

State, the District of Columbia, Puerto Rico, or a Territory of the U.S., and currently ( ) is ( ) is not suspended in any state, District of Columbia, or Puerto Rico.

I currently hold an active medical license(s) in the following State(s):

State License No. Issued Date

I have an inactive medical license(s) in the following State(s). *

State License No. Issued Date

I am board ( ) certified ( ) eligible in the specialty of __________________________.

*Include reason license has lapsed or is inactive.

I hereby certify that for the purposes of application of the false statements provisions of the Program Fraud Civil Remedies Cat of 1986 (45 CFR 79), that to the best of my knowledge, each of the above statements is true, accurate, and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission.

Original Signature of Provider Date

Name of Provider (typed or printed) Date