Prior Conduct Questionnaire Prior Conduct Questionnaire 2025

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The document is a Prior Conduct Questionnaire designed for healthcare providers to disclose their prior conduct related to Medicare and Medicaid. It requires detailed responses regarding any exclusions, terminations, suspensions, convictions, or sanctions related to these federal and state programs. The form emphasizes the importance of thoroughness and accuracy in responses, as incomplete information may lead to application delays or denials. Additionally, it includes sections for documenting corrective actions taken by the applicant.

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Click ‘Get Form’ to open the Prior Conduct Questionnaire in the editor.
Begin by entering your full name and New York State Provider ID # at the top of the form. Ensure that all information is accurate to avoid processing delays.
In Section I, A, answer whether you have ever been excluded, terminated, or suspended by Medicare. If yes, provide detailed information including dates and reasons in the designated fields.
Proceed to Section I, B, and respond to questions regarding your Medicaid history. Be thorough in detailing any exclusions or sanctions.
Continue through Sections II and III, addressing any convictions related to fraud or misconduct. Attach additional sheets if necessary for comprehensive responses.
Finally, review all entries for accuracy before signing and dating the form at the bottom. This ensures your application is complete and ready for submission.

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