D7_PROVIDER CERTIFICATION.pdf
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- Attached to
- Non-Personal Healthcare Services-Physicians & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70726R00002
About this file
This is a medical provider certification form used in federal contracting to verify the qualifications and licensure status of healthcare professionals. The form requires providers to document their educational background, including the name and location of their degree-granting institution, year of graduation, and the type of degree or certificate awarded (nursing, medicine, etc.). Providers must also disclose whether they graduated from a foreign university and, if applicable, provide evidence of passing the FLEX or ECFMG examination.
The certification requires disclosure of the provider's current active medical licenses by state, license number, and issue date, as well as any inactive licenses with explanations for their lapsed or inactive status. Providers must confirm whether their license has been terminated, suspended, or revoked in any U.S. state, the District of Columbia, Puerto Rico, or U.S. territories, and whether it is currently suspended. The form also requests board certification or board eligibility status in the provider's specialty. The provider must sign and date the form, certifying under penalty of perjury pursuant to the Program Fraud Civil Remedies Act of 1986 (45 CFR 79) that all statements are true, accurate, and complete, with no material omissions.
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Text version
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 .