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Get Prior Conduct Questionnaire
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How to fill out the PRIOR CONDUCT QUESTIONNAIRE online
The PRIOR CONDUCT QUESTIONNAIRE is an essential document that requires thorough and accurate responses regarding your prior conduct and history with Medicare and Medicaid programs. This guide provides step-by-step instructions to assist you in successfully completing this form online.
Follow the steps to complete the PRIOR CONDUCT QUESTIONNAIRE effectively.
- Press the ‘Get Form’ button to access the PRIOR CONDUCT QUESTIONNAIRE. This will allow you to open the document in an online editor.
- Begin filling in your personal details at the top of the questionnaire. This includes your applicant name, New York State Provider ID number, and NPI number.
- Complete Section I regarding your prior Medicare history. Answer each question truthfully, selecting 'Yes' or 'No' as applicable. If you select 'Yes', provide the requested details such as dates and reasons.
- Proceed to Section II, which covers any criminal convictions related to Medicare and Medicaid programs. Again, respond adequately to each prompt, giving complete information as required.
- Continue to Section III, where you will need to specify the status of your medical license. Indicate if your license has ever been revoked, suspended, or surrendered and provide the necessary details.
- In Section IV, disclose any pending proceedings that may result in sanctions. Check all applicable sanctions and provide a date for the expected decision.
- After completing all sections, review your answers to ensure they are thorough and accurate. If necessary, attach additional sheets for clarity or to provide more information.
- Once satisfied with your responses, you can save your changes. Options typically include downloading the form, printing it, or sharing it via email.
Complete your PRIOR CONDUCT QUESTIONNAIRE online today to ensure a smooth application process.
The administration of New York's Medicaid program rests primarily with the State Department of Health (DOH), which is designated as “the single state agency,” responsible under federal law for supervising the program.
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