D7_PROVIDER_CERTIFICATION (2).pdf
PDF 12 KB Posted
- Attached to
- Non-Personal Healthcare Services-Physician & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70725R00008
About this file
This is a medical provider certification form template required as part of solicitation 75H70725R00008 for non-personal healthcare services for the Indian Health Service's Purchased/Referred Care Program.
The form requires healthcare providers to document their educational background, foreign/domestic university status, FLEX/ECFMG exam completion if applicable, medical license status across all U.S. states and territories, active and inactive license numbers with dates, and board certification/eligibility in their medical specialty. The form includes a certification statement regarding the Program Fraud Civil Remedies Act of 1986 (45 CFR 79) that providers must sign to verify the accuracy and completeness of the information provided.
View the file
Other files
Show all 13
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
RFP
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
File details come from the government source that posted it. Updated .