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Optional:  Receive a for

Quality Assessment

Completion of our Quality Assessment Form .

Quality Assessment Form

Today's Date

Lessee  -  Individual, Company or

Doctors/Opticians Included:

Please answer all Applicable Questions:

Yes No
Has your license to practice medicine ever been restricted, limited, revoked, suspended, or in any way changed by a state licensing or medical
disciplinary board?
Have your hospital privileges ever been restricted or changed without your specific request for such a change or restriction?
Have you ever been denied initial hospital privileges, not had them renewed despite reapplication, or had them terminated?
Have you been refused a requested specialty, medical or professional
society membership?
Have you ever been refused medical malpractice insurance or been refused renewal of your medical malpractice?
Have you ever had an alleged medical malpractice action filed against you that has resulted in an out of court settlement, court ordered settlement, or judgment against you?
Do you currently have any alleged medical malpractice actions filed against you, pending or have suspicion of an imminent such action against you?
Have you ever been convicted of a felony?
Are you board certified?
Have any complaints been filed against you with a medical/professional
society within the last two years?
Lessee  Representative:


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