Health Care Renewal Notice Health Care Renewal Notice
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1Arkansas State Medical Board
Centralized Credentials Verification Service
Phone: (501) 296-1951
Fax: (501) 296-1806
CCVS ATTESTATION & RENEWAL FORM
DO NOT ALTER THE QUESTIONS ON THIS ATTESTATION FORM!!!
Yes ____ No ____ Do you currently maintain individual or group malpractice insurance coverage? If NO, list reason: ___________________________
Policy number (s): _________________________ Coverage amounts: _____________________________________ Expiration date: ______________
Insurance Carrier(s)Name: ___________________________________If Group (
):________________________________
List Group Name Policy is under
__________________________________________________________________________________________________________________________
Yes ____ No _____Will you be providing telemedicine services from another state (an act that is part of patient care through electronic means)?
If you answer YES to any of the following questions, provide an explanation of the circumstances on an attached page.
1.
Yes ____ No ____ Since your last attestation, have your privileges or medical staff membership at any hospital or other healthcare organization
been denied, suspended, diminished, voluntarily or involuntarily relinquished, revoked or not renewed, or is any such action pending?
If YES,
briefly explain on attached page.
2.
Yes ____ No ____ Since your last attestation, have you been charged or convicted of (including a plea of guilty or nolo contendere) a felony?
(NOTE: Applicants must answer affirmatively if records, charges, or convictions have been pardoned, expunged, plead down, released or sealed.)
If YES, briefly explain on attached page or attach copies of your documents.
3.
Yes ____ No ____ Since your last attestation, has your license or certificate to practice medicine or Drug Enforcement Administration
registration in any jurisdiction (state or country) been challenged, denied, reduced, limited, suspended, revoked, placed on probation, not renewed,
voluntarily or involuntarily relinquished, or is any such action pending?
If YES, briefly explain on attached page.
4.
Yes ____ No ____ Since your last attestation, have you been or are you presently being treated for alcoholism or substance abuse due to an Order
of the Arkansas State Medical Board or an Order of the medical licensing authority of any other state?
If YES, briefly explain on attached page.
5.
Yes ____ No ____ Since your last attestation, have you been advised or required by the Arkansas State Medical Board or any other licensing
board to seek treatment for a physical or mental health condition?
If YES, briefly explain on attached page.
6.
Yes ____ No ____ Since your last attestation, do you currently, or have you had since your last renewal, any physical or mental health condition,
including alcohol or drug dependency, which, with or without accommodation, affects or is reasonably likely to affect your ability to practice
medicine or to perform professional or medical staff duties appropriately?
If YES, briefly explain on attached page.
7.
Yes ____ No ____ Since your last attestation, are you presently involved in the use of any illegal substance?
If YES, briefly explain on attached page.
8.
Yes ____ No ____ Since your last attestation, have any malpractice claims or professional liability lawsuits been filed against you, or have you
received notification of a suit alleging you have committed medical malpractice?
If YES, briefly explain on attached page.
CLAIM DATE _____/_____/_____ CLAIMANT’S INITIALS ______________________.
ASMB Requirement (Medical Practices Act 17-95-103)
9.
Yes ____ No ____ Since your last attestation, have any malpractice judgments been entered against you, or settlements been agreed to, in
professional liability lawsuits or malpractice claims?
If YES, briefly explain on attached page or attach documents.
CLAIM DATE ______/______/______ CLAIMANT’S INITIALS _____________________.
10.
How many CME credits have you acquired since your last AR license renewal? _______How many relate to your practice specialty? ________.
If you have not participated in any continuing medical education, list reason: _____________________________________________________.
ATTESTATION – ALL QUESTIONS MUST BE ANSWERED
(if not applicable, put N/A in blank)
I affirm that all information contained in the original application or most recent update is true, correct, current, and complete in all respects to
the best of my ability. I accept the responsibility to keep the Arkansas State Medical Board advised of any change or appropriate addition to
any information contained in this form between now and the time such information is updated by subsequent renewals or updates.
________________________________________________________________________________________________________________________
Licensee’s Signature (Required)
(No Rubber Stamps)
Date Signed (Month/Day/Year - Required)
__________________________________________________
_________________________
Licensee’s Printed/Typed Name (Required)
AR License Number (Required)
H:CCVS FORMSAttestation CCVS and LRNL 1 16 09ANM.doc; Attestation Web Rev. 12/11/03 LJM; Rev. 5/02/06 ANM; Rev 6/20/07 ANM;
Rev 1/16/09 ANM
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