ATTACHMENT C - CERTIFICATION OF EDUCATION AND INSURANCE.pdf

Attachment C.

CERTIFICATION OF EDUCATION & LICENSURE

I graduated from the (Name of educational institution) located in in the year of and was awarded a degree/certificate in (RN, MD, OD, etc.)

I currently hold license number(s) that expires to practice medicine in the State(s) of subject to the following restrictions (If no restrictions, so state)

My license to practice has-, has not- been terminated, restricted or revoked within the last 10 years, and is-, is not- currently suspended in any State, the District of Columbia, or Puerto Rico.

Please indicate which of the following applies to you:

I am Board Certified in the specialty(s) of

I have completed a full residency training program and am eligible to take the board examination in the specialty(s) of

I am not Board Certified nor eligible.

I have current medical malpractice insurance in the amount of $

Expiration date:

Medical malpractice carrier

I have-, have never-, been suspended from participating in Medicare, Medicaid, or another Federal, State, or local medical program.

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

Original Signature of Practitioner Date

Printed or Typed Name

CERTIFICATION OF EDUCATION & LICENSURE