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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

N.Has your request for any specific clinical privileges or scope of practice ever been denied (as a result of disciplinary action) or granted with stated limitations or conditions (aside from ordinary initial probationary requirements of proctorship)?  Are such proceedings currently pending?

No

Yes

O.Do you have any knowledge of any civil actions pending against you by any hospital, law enforcement agency, professional group or society?

No

Yes

P.Have you had any charges of unprofessional conduct brought against you?

No

Yes

Q.Have you had any charges of fraud brought against you?

No

Yes

R.Have you received any confirmed Quality Citations from a Peer Review Organization (PRO) in the last two (2) years?   If you answered yes, on a separate sheet, indicate the address of the PRO that cited you, the circumstances of the citation and the number of points you were fined.

No

Yes

Health Status

Note: Your application will be processed in the usual manner regardless of how you answer questions A and B.  If you have answered “No” to question A or B, please explain completely on a separate sheet.  If you are found to be qualified, a representative will contact you to determine what accommodations are necessary and feasible to allow you to practice safely.

A.Are you physically and mentally able to perform all the essential functions or services necessary to exercise the privileges or services applied for with or without a reasonable accommodation?

 Yes

 No

B.Are you able to perform these functions without significant risk of injury to yourself or others?

 Yes

 No

C.

Do you illegally use drugs?

Have you used illegal drugs within the last two years?

 Yes

 Yes

 No

 No

D.Do you currently take any medications that may affect your ability to perform the clinical privileges or scope of practice requested competently and safely?

 Yes

 No

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 19

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