TN 3 (01-12)
DI 39569.400 Exhibit 1 - License and Credentials Certification for Consultative Examination Provider
and Certification of All Support Staff
I hereby certify that:
I am not currently excluded, suspended, or otherwise barred from participation in
the Medicare or Medicaid programs, or any other federal or federally assisted programs.
The support staff I use who participate in the conduct of consultative examinations,
and any third parties who conduct other studies purchased by the Disability Determination
Services (DDS), meet all appropriate licensing or certification requirements of the
State, as required by the Social Security Administration’s (SSA) regulations (20 C.F.R. 404.1519g , and 416.919g ); and, not currently excluded, suspended, or otherwise barred from participation
in the Medicare or Medicaid programs, or any other federal or federally assisted programs,
as required by SSA’s regulations (20 CFR 404.1503a , and 416.903a ).
My license is current and active and has not been revoked or suspended by any State
licensing authority for reasons bearing on professional competence, professional conduct,
or financial integrity.
I have not surrendered my license while awaiting final determination on formal disciplinary
proceedings involving professional conduct.
I understand that a credentials check will be made upon my initial agreement to perform
services and periodically thereafter by the DDS.
I will immediately notify the DDS if there is any pending disciplinary action against
my license. Failure to do so could result in termination of an agreement to perform
services and/or legal action.
I certify that, to the best of my knowledge and belief, all of the information on
this form is correct. I understand I will not be considered for an agreement to provide
services if I am unable to certify to the above; and, false certification will be
grounds for termination of any resulting agreement to provide services.
Signature ____________________________________ Date ______________