A. Do you agree that your license to provide health care was revoked,
suspended, or otherwise lost as a consequence of action taken by a State
licensing authority?
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
B. Do you agree that your license to provide health care was revoked,
suspended, or otherwise lost for reasons bearing on your professional
competence, professional performance, or financial integrity?
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
C. (Answer the following question only if your license to provide
health care was lost, suspended, or otherwise revoked based on an
agreement reached between you and a State licensing authority). Do
you agree that you surrendered your license to provide health care while a
State formal disciplinary proceeding was pending against you and the
proceeding concerned your professional competence, professional
performance, or financial integrity?
No
Yes
No
Yes
No
Yes