2020 AAPdN Annual Attestation

Member Information

First Name *

Middle Initial

Last Name *

Degree *

Address 1 *

Address 2

City *

State *

Zip *

Office Phone *

Mobile Phone

Alternate Phone

Email Address *

Please answer the following: If any of your answers below are “YES,” please provide details at the bottom of this form:

Please answer the following questions regarding the past year:

1. Has your professional liability insurance coverage ever been terminated by action of an insurance company? *

YES

2. Have you been denied professional liability insurance coverage or rated in a higher than average risk class for your professional specialty? *

YES

3. Have any disciplinary actions ever been initiated and/or are any pending now against you by any state licensing board, whether or not you were a member of the professional standards board initiating said action? *

YES

4. Has your license to practice psychology in any state been denied, limited, suspended, revoked or voluntarily relinquished? *

YES

5. Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program (for example, Medicare, Medicaid, or any managed care company)? *

YES

6. Have you been the subject of an investigation by any state, federal, or private agency concerning your participation in any state, federal, or private, health insurance program? *

YES

7. Has your application for appointment or reappointment, or your privileges at any hospital or other health care facility ever been denied, reduced, suspended or not renewed? *

YES

8. Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any professional organization? *

YES

9. Have any professional liability claims, suits, or judgments ever been made against you or are such claims, suits, or judgments currently pending or have you ever been made aware that any will be filed? *

YES

10. Have you ever been convicted of a felony or misdemeanor other than minor traffic violations? *

YES

11. Have you ever had, or are you currently aware of having any physical, mental or emotional condition, or chemical dependency/substance abuse problem which may interfere with your ability to care for patients in any way? *

YES

If any of your answers were YES to any of the questions above, please provide detailed information below.

I certify that all of the information provided herein is accurate. I understand and agree that if any of the information I have provided is proven to be false or misleading, if in the future my behavior results in the probation or suspension of my license, or I become the subject of an ethics investigation on the part of the APA or my State Psychological Association, my board certification status may suspended or revoked. I agree to use my credentials appropriately and will not use the ABPdN credentials or any other credentials that I might have to mislead consumers or colleagues to believe that I have been trained or examined in areas other than that both truthful and accurate. I understand that to retain my board certification, I must be licensed to practice at the independent level as defined in the ABPdN bylaws.

Please sign below by typing your name. *

Date: *

If you have any questions, please contact:

Grace A. Mucci, Ph.D., ABPdN

5855 E. Naples Plaza, Suite 203

Long Beach, CA 90803

(949) 478-4503

Email: gmucciaapdn@gmail.com