Professional Attestation (Please check all statements that apply to you) My license to practice dentistry has not been revoked, suspended, pla.ced on probation, voluntarily relinquished or subject to disciplinary action by a state licensing authority or professional organization in the past five (5) years. I have not had any adverse malpractice settlements or judgements against me in the past five (5) years. I do not have any malpractice or other professional liability claims currently pending against me. I do not currently or have not in the past five (5) years been excluded from participation in Medicare/Medicaid or any other federal health care programs. I have not been convicted of a felony (s) and am not currently under investigation. I have not been denied DEA (Drug Enforcement Administration) or CDS (Controlled Dangerous Substance) certification. I have not had a physical condition, mental condition, substance or chemical dependency that interferes or has interfered with my ability to practice dentistry either with or without accommodations. My hospital privileges are either in good standing or I do not perform services in a hospital setting. By checking this box I certify that I follow the current recommendations of the American Dental Association and/or the Centers for Disease Control regarding infection control.

Certification By checking this box, I certify that all the information herein is accurate and true to the best of my knowledge and agree to notify Delta Dental, in writing, of any changes in this document within thirty (30) days of their occurrence. I understand that information found to be false could result in denial/termination of participation status with Delta Dental.