Malpractice History And Clinical Privileges Questionnaire - Apd - Form 5754
Download a blank fillable Malpractice History And Clinical Privileges Questionnaire - Apd - Form 5754 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Malpractice History And Clinical Privileges Questionnaire - Apd - Form 5754 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2MALPRACTICE HISTORY AND CLINICAL PRIVILEGES QUESTIONNAIRE
For use of this form, see AR 40-68; the proponent agency is OTSG.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 5, United States Code (USC), Sections 301 and 552a; Title 44, USC, Section 3101; Title 10, USC, Section 1071.
Authority:
To document the provider's professional qualifications as the basis for clinical privileges and staff appointment.
Principal Purpose:
To support the credentialing and privileging processes. A copy of this form will be retained in provider credentials file.
Routine Uses:
Information may be provided to certain civilian institutions, the Federation of State Medical Boards of the U.S., State
Licensure Authorities, and other appropriate professional regulatory bodies.
Disclosure of information requested is voluntary. However, failure to provide the required information may interfere
Disclosure:
with the timely granting of your clinical privileges or professional staff appointment.
INSTRUCTIONS. This form is to be completed by all health care providers (military/civilian) upon initial entry or re-entry into Federal Service,
and as part of the periodic clinical privileges renewal process.
1. NAME OF PROVIDER (Last, First, MI)
2. RANK/GRADE
3. DATE OF BIRTH (YYYYMMDD)
4. SPECIALTY/AOC
5. MEDICAL/DENTAL FACILITY (Name and Address: City/State/Zip Code)
6. Place a check (X) in the column that corresponds to your answer to each of the following questions. (Any "YES" answer must be fully explained on the
bottom of this page in block 8.) Note: An answer is required for every question.
YES
NO
ARE YOU NOW OR HAVE YOU EVER:
a.
Been required to appear before any medical or State regulating authority, regardless of the result, concerning your status
as an impaired, hindered, or otherwise restricted provider?
b. Had a history of alcohol or other drug abuse or misuse?
c.
Had your narcotics registration suspended or revoked?
d. Had your professional privileges voluntarily or involuntarily denied, revoked, suspended, reduced, or restricted by a health
care facility?
e.
Had your request for any specific clinical privilege(s) denied or granted with specific limitations?
f.
Voluntarily or involuntarily resigned or otherwise disassociated yourself from employment or practice after being notified of
the intent to initiate action against you for failure to properly execute your professional responsibilities?
g. Had medical liability claims, settlements, judicial or administrative adjudications, or any other resolved or open charges of
inappropriate, unethical, unprofessional, or substandard professional practice?
h. Had your professional license voluntarily or involuntarily denied, restricted, withdrawn, suspended, or revoked by a State or
local licensing board or other authority?
i.
Been asked to voluntarily surrender your license?
j .
Had a previously successful or currently pending challenge(s) to any license or registration (e.g., State or District, Drug
Enforcement Agency, etc.) that you hold now, or have held?
k.
Been refused membership in an institution's medical or dental staff?
l.
Been denied membership, or renewal thereof, or been subject to disciplinary action in any medical/dental organization?
m. Been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance
programs (i.e., Medicare or Medicaid)?
n. Had your professional liability coverage canceled, limited, denied, or not renewed?
7. COMMENTS. Note item by number (6a. - 6n.) and provide clarification of any question with a "YES" answer. Include clarification for any
circumstance not already addressed in detail on a previous DA Form 5754. (Continue on a separate page.)
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
DA FORM 5754, APR 2009
APD LC v1.00ES
EXEMPT FROM DISCOVERY UNDER 10 U.S.C. 1102
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Business, Sales/use Tax, Lodgers Tax Licenses And Occupational Privilege Tax Registration Form
Financial
Clinical Laboratory Technologist/technician Form 4c - Certification Of Expierence And Competence
Legal
Form Wv/sev-400h - Monthly Estimate Of Severance And Business Privilege Taxes For Providers Of Health Care Items And Services
Financial
Related Categories
Parent category: Financial