VERIFICATION_OF_ACTIVE_AND_INACTIVE_MEDICAL_LICENSE.docx
DOCX document 16 KB Posted
- Attached to
- PSYCHIATRY SERVICES Federal contract opportunity
- Solicitation number
- RFP-244-14-0009-REL
About this file
The attached certificate must be completed and submitted for each psychiatrist being presented.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 52.212_3.MAY_2014.doc | DOC document |
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VERIFICATION OF ACTIVE AND INACTIVE MEDICAL LICENSE(S)
Prospective contractors are subject to the same quality assurance, credentials, licensure, and qualification standards as required of IHS personnel. In addition, health care providers, other than paraprofessionals, must be licensed in the United States, the District of Columbia, Puerto Rico, or a Territory of the United States to perform the contract services within IHS facilities.
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.
I currently hold an active medical license in the following State(s):
| State |
| License No. |
| Issue Date |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
I currently hold an inactive medical license in the following State(s):
| State |
| License No. |
| Inactive Date |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
| _________ |
I hereby certify that for the purposes of the 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 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.
| ________________________________ | __________ | |
| Signature of Practitioner | Date |
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