Kroll Corporate Services

SMITH, JOE

Date Requested:	28-Dec-2000 04:16:22 PM CST
Ref. No.:	450549

CLIENT INFORMATION

Client:	DEMO - STANDARD
Address:	1900 CHURCH ST
City:	NASHVILLE, TN 37203
Phone:	123-456-7890
Requestor:	Josephine User

Acct No:	531
District:
Location:	07-Nashville
Department/Position:	Medical Staff Office/Physician
Client:	HealthyHealthcare, Inc.
Sales Rep.:	J

SUBJECT INFORMATION

Title:	Dr.
Name:	SMITH, JOE
Address:	207 ARLINGTON DRIVE
	LOS ANGELES, CA 99845

SSN:	123-45-6789
Birthdate:	03/15/1965

SERVICES ORDERED

Demo Package 2

County Criminal	Driving Record
FACIS	National Wants & Warrants
Prof Liability Coverage & Malpractice History	Social Security Trace
State Criminal	Verification of Clinical Reference - Physician
Verification of Institutional Privileges & Status

QA: K L	Status: QA
QA Date: 31-Dec-2001 12:00 AM

Notice:

The information contained herein should not be the sole determinant in an evaluation of the above-listed individual.

THIS REPORT IS SUBMITTED IN STRICT CONFIDENCE AND EXCEPT WHERE REQUIRED BY LAW, NO INFORMATION PROVIDED IN THIS REPORT MAY BE REVEALED DIRECTLY OR INDIRECTLY TO ANY PERSON EXCEPT TO ONE WHOSE OFFICIAL DUTIES REQUIRE THEM TO PASS ON THE TRANSACTION IN RELATION TO WHICH THIS REPORT WAS ORDERED.

Kroll Background America, neither warrants, vouches for, or authenticates the reliability of the information contained herein except that the records are accurately reported as they were found at their source as of the time/date written below, whether on a computer information system or retrieved by manual search or telephonic interviews. The information provided herein shall not be construed to constitute a legal opinion; rather it is a compilation of public records/data for your review.

THIS REPORT CONTAINS PUBLIC RECORD INFORMATION THAT IS REPORTABLE UNDER THE FAIR CREDIT REPORTING ACT OR OTHER FEDERAL LAWS. HOWEVER, THE INTENDED USE OF THIS INFORMATION BY THE USER MAY BE RESTRICTED BY SEPARATE STATE AND/OR LOCAL LAWS.

County Criminal

Name Searched:	SMITH, JOE
Search Period:	9/5/1993 - 9/5/2000
County:	Los Angeles
State:	CA
Charge:	AGGRAVATED ASSAULT
Type:	FELONY
Arrest/Charge Date:	03/31/1998
Case No:	NJ97CR
Disposition:	SENTENCED TO 3 YRS IN JAIL, 1 YR SUSPENDED, ANGER MANAGEMENT CLASSES, FORFEIT WEAPON, FINED AND RESTITUTION
Disposition Date:	8/14/1998
Remarks:	RECORD FOUND UNDER NAME, DATE OF BIRTH AND SSN.
Courts Checked:	SUPERIOR AND MUNICIPAL COURTS
Actual Source:	SEE ABOVE

Driving Record

Remarks:

Bureau Results:

KBA DRIVER RECORD SERVICE REPORT FOR GA



 Report Date: 09052000

 ================================================================================

  Licensee Name/Address

  ---------------------------------------

 JOE SMITH                           

 360 APPLE LANE                

 ATLANTA, GA 55778

  Comment:

  ---------------------------------------

                                        

 ================================================================================

  License Number             DOB       Driver Description              SSN

  -------------------------  --------  ------------------------------  ---------

  T653098636482              06241965  S:F                                      



  Issued     Expired     License Class      Restrictions            Status

  --------   --------    ---------------    --------------------    ------------

                                                                             

 ================================================================================



               *** STATE SPECIFIC INFORMATION ***



 Type Description

 --------------------------------------------------------------------------------





 

 LIC CLASS:

 

 RESTR:  CORRECTIVE LENS

 

 


 03/04/1997  GEORGIA - DRIVING UNDER INFLUENCE

FACIS

Requested Info
First Name:	JOE
Middle Name:
Last Name:	SMITH
Result Info
Repository Searched:	FRAUD AND ABUSE DATA REGISTER
Remarks:	NO RECORDS FOUND AS OF 9/5/2000

National Wants & Warrants

Name Searched:	SMITH, JOE
Date of Birth:
Wanted For:	N/A
Where Wanted:	N/A
Case Number:	N/A
Date Issued:	N/A
Source of Data:	AUTHORIZED LAW ENFORCEMENT AGENCY
Remarks:	NO RECORDS FOUND AS OF 9/5/2000

Prof Liability Coverage & Malpractice History

First Name: JOE
Middle Name:
Last Name: SMITH
"Policy Number?"
JS123456789
"Date of Initial Coverage?"

"Current Status of Policy?"

"Expiration Date?"

"Coverage Type?"

"Aggregate Coverage Limit?"


1) Name and Title of Source Verifying Information?
MICHAEL TESTER, CLAIMS MANAGER, NATIONAL PROTECTIVE, INC.
2) Policy Number?
JS123456789
3) Date of Initial Coverage?
January 1, 1998
4) Status of Policy?
Lapsed
5) Expiration Date?
January 1, 2001
6) Coverage Type?
Occurrence Policy
7) Aggregate Coverage Limit?
1 Million/3 Million
8) Have Any Specific Procedures been Excluded From This Policy? If Yes, Please Explain?
NO
9) Has the Applicant Ever Been Denied Professional Liability Coverage or Has His/Her Policy ever Been Cancelled or Denied Renewal?
NO
10) If Yes (To Question 9): When was the Policy Denied/Cancelled?

11) If Yes (To Question 9): Why was the Policy Denied/Cancelled?

12) If Yes (to question 9): When was the Policy Reinstated?

13) Have there Ever Been, or Are There Currently Pending, Any Claims, Suits, Settlements, or Any Intent to File a Suit?
YES
14) If Yes (To Question 13) When and Where?
5 CLAIMS FILED UNDER THIS POLICY - VALPALOOSA COUNTY
15) If Yes (to question 13): What were the Circumstances Surrounding the Claim, Suit or Settlement?
TWO WERE SETTLED PRIOR TO COURT DATE, ONE IS IN ACTIVE LITIGATION. OTHER TWO WERE COURT DECISIONS.
16) If Yes (to question 13): What was the Outcome?
TWO WERE SETTLED ON BEHALF OF PLAINTIFF. ONE IS IN ACTIVE LITIGATION. OTHER TWO WERE COURT DECISIONS, ONE IN FAVOR OF JOE SMITH AND THE OTHER NOT IN HIS FAVOR.
17) If Yes (to question 13): When was the Case Disposed?
TWO IN JULY 2000, TWO IN SEPTEMBER, 2000 AND DECEMBER, 2000
18) Is there Any Additional Information that would Assist Us in Evaluating the Clinical Abilities and Other Skills of this Applicant?

Social Security Trace

First Name:	JOE
Middle Name:
Last Name:	SMITH
Social Security Number:	123-45-6789
Bureau Searched:	Experian (auto)
Remarks:
Bureau Results:
PAGE 1 DATE 8-01-2000 TIME 15:24:07 PCA03 V401 JOE SMITH SS: 123-45-6789 360 APPLE LANE DOB: 01/09/1965 ATLANTA, GA 55778 SP: L RPTD: 8-1990 TO 6-1993 4X 1700 N SCHOOL ST APT 32 TAMPA, FL 61761-1023 RPTD: 5-1994 TO 2-1998 207 ARLINGTON DR LOS ANGELES, CA 99845 RPTD: 1999 TO 2000 SAMUEL SPICER END -- EXPERIAN

State Criminal

Name Searched:	SMITH, JOE
Search Period:	9/5/1993 - 9/5/2000
State:	GA
Charge:	3 COUNTS OF DRUG RECEIPT UNDER FALSE PRETENSES
Type:	MISDEMEANOR
Arrest/Charge Date:	5/6/1995
Case No:	BT95CR
Disposition:	GUILTY; SENTENCED TO 4 YRS IN PRISON, 2 YRS SUSPENDED, 2 YRS PROBATION; FINED AND RESTITUTION
Disposition Date:	2/15/1996
Remarks:	RECORD FOUND UNDER NAME, DATE OF BIRTH AND SSN.
Repository:	GEORGIA CRIMINAL INFORMATION CENTER
Source of Data:	SEE ABOVE

State Criminal

Name Searched:	SMITH, JOE
Search Period:	9/5/1993 - 9/5/2000
State:	FL
Charge:	NONE
Type:	N/A
Arrest/Charge Date:	N/A
Case No:	N/A
Disposition:	NONE
Disposition Date:	N/A
Remarks:	NO RECORDS FOUND
Repository:	FLORIDA DEPARTMENT OF LAW ENFORCEMENT
Source of Data:	SEE ABOVE

Verification of Clinical Reference - Physician

First Name: JOE
Middle Name:
Last Name: SMITH
"Name of Clinical Reference"

"Phone/Fax/Email of Clinical Reference"

"Applicant's Position and Title"

"Applicant's Clinical Area of Practice"


1) Name and Title of Source that is Verifying the Information?
JANE FALLS, MD.
2) What is Your Relationship to the Applicant?
COLLEGUE
3) How Long Have You Known the Applicant?
2 YEARS
4) In what Clinical Area did the Applicant Practice?
Internal Medicine
5) To Your Knowledge, Has the Applicant ever had a Physical Illness/Emotional Illness/ or a Substance Abuse Problem that could Impair or Restrict their Ability to Perform Privileges that have been Requested?
NO
6) If Yes (To Question 5) Describe the Nature of the Illness/Condition/Substance Abuse Problem?

7) If Yes,(To Question 5) How did the Illiness/Condition/Substance Abuse Problem Impair/Restrict Their Ability?

8) If Yes (To Question 5) What was the duration of the Illness/Condition/Substance Abuse Problem?

9) If Yes (To Question 5)What Type of Treatment was Received by the Applicant?

10) Have you Received Any Notable Complaints Against the Applicant?
NO
11) If Yes, (to Question 10) When was the Complaint Filed?

12) If Yes, (to Question 10) Describe the Circumstances Surrounding the Complaint?

13) If Yes, (to Question 10) How was the Complaint Resolved?

14) If Yes, (to Question 10) Was the Incident Brought Before a Review Board? If so, When?

15) Has the Physician Ever been Subject to Any Disciplinary Action?
NO
16) If Yes, (to Question 15) What Type of Disciplinary Action was Taken?

17) If Yes, (to Question 15) When was the Disciplinary Action Taken?

18) If Yes, (to Question 15) For What Reason Was the Disciplinary Action Taken?

19) Does the Applicant Regularly Obtain Consultations When Needed?
YES
20) If No, (to Question 19) Please Describe Each Situation when the Applicant Did not Obtain Consultation When Needed?

21) Did the Applicant Always Conform to Medical Staff Bylaws?
YES
22) If No, (to Question 21) When and on How Many Occasions Did the Applicant Not Conform to the Bylaws?

23) If No, (to Question 21) Please Elaborate on Each Non-Conformance?

24) Would you be Comfortable having this Practitioner as a Partner, Colleague, or Close Associate? ....If No, Please Explain your Apprehension?
YES
25) Does the Applicant Have Adequate Communication Skills, to Include the Ability to Understand, Read, and Write English?...If No, What is the Applicant's Primary Language of Communication?
YES
26) Please Rate the Applicant's Ability in the Following Categories by Indicating Excellent, Average, Poor or Unknown:

27) Clinical Competence?
EXCELLENT
28) Technical Skill?
AVERAGE
29) Clinical Knowledge?
AVERAGE
30) Professional Performance?
AVERAGE
31) Professional Attitude?
EXCELLENT
32) Judgement?
EXCELLENT
33) Ability to Get Along with Others?
EXCELLENT
34) Efficient Use of Hospital Resources?
AVERAGE
35) Quality of Medical Record Entries?
AVERAGE
36) Timeliness of Medical Record Completion?
AVERAGE
37) Is there any Additional Information that would Assist us in Evaluating the Clinical Abilities and other Skills of this Applicant?

Verification of Institutional Privileges & Status

First Name: JOE
Middle Name:
Last Name: SMITH
"Name of Clinic/Institution"
Rq_Retort1
"Phone/Fax/Email of Clinic/Institution"
Rq_Retort2
"Applicant's Clinical Privileges"

"Date of Staff Appointment and Granting of Privileges"


1) Name and Title of Source that is Verifying the Information?
SALLY LANE, MEDICAL STAFF COORDINATOR,MEMORIAL HOSPITAL
2) What was the Date of the Applicant's Initial Medical Staff Appointment and Granting of Privileges?
APPOINTED JUNE 4, 1998
3) What Clinical Privileges Did this Applicant Have at Your Institution?
GENERAL INTERNAL MEDICINE INCLUDING CRITICAL CARE.
4) Did this Applicant Have Any Special Privileges? If Yes, Please Explain?
NO
5) Have the Applicant's Clinical Privileges or Memberships Ever Been Limited, Suspended, or Revoked?
YES
6) If Yes (to question 5): What Clinical Privilege or Membership was Affected?
CRITICAL CARE PRIVILEGES
7) If Yes (to question 5): Was The Privilege or Membership Limited, Suspended, or Revoked?
REVOKED
8) If Yes (to question 5): For What Reason Was the Privilege or Membership Limited, Suspended, or Revoked?
ALL INFORMATION INCLUDED IN THE REPORT FILED WITH NPDB.
9) If Yes (to question 5): When Was the Privilege or Membership Limited, Suspended, or Revoked?
July 1999
10) If Yes (to question 5): Has the Privilege or Membership Been Reinstated? Is Yes, When?
NO
11) Has Any Disciplinary Action Been Taken Against the Applicant?
YES
12) If Yes (to question 11): What Type of Disciplinary Action was Taken?
PHYSICIAN REQUIRED TO PARTICIPATE IN CONTINUING EDUCATION.
13) If yes (to question 11): When Was the Disciplinary Action Taken?
SEPTEMBER 1999
14) If Yes (to question 11): For What Reason Was the Disciplinary Action Taken?

15) Has the Applicant Resigned Privileges to Avoid Disciplinary Action?
NO
16) If Yes (to question 15): What Date Did the Applicant Resign his/her Privileges?

17) If Yes (to question 15): Describe the Circumstances Surrounding the Situation Leading to the Resignation?

18) To Your Knowledge, Has the Applicant Ever Been a Defendant in a Felony Criminal Matter?
NO
19) If Yes (to question 18): When and Where (County, City, & State)?

20) If Yes (to question 18): Describe Any Details That You Are Aware of Regarding the Matter?

21) Have You Received Any Formal Complaints Against the Applicant?
YES
22) If Yes (to question 21): When Was the Complaint Filed?
FEBRUARY, 1999
23) If Yes (to question 21): Describe the Circumstances Surrounding the Complaint?
FAMILY OF A PATIENT COMPLAINED OF PROBLEMS WITH QUALITY OF CARE.
24) If Yes (to question 21): How Was the Compliant Resolved?
DISCIPLINARY ACTION WAS TAKEN.
25) If Yes (to question 21): Was the Incident Brought Before a Review Board? If so, When?
MARCH, 1999
26) Does the Applicant Get Along Well with Other Staff and Employees? If No, Please Explain?
YES
27) Did the Applicant Always Conform to Medical Staff Bylaws?
NO
28) If No (to question 27): When and on How Many Occasions Did the Applicant Not Conform to the Bylaws?
SEE NPDB REPORT
29) If No (to question 27): Please Elaborate on Each Non-Conformance?

30) Is There Any Additional Information that Would Assist Us in Evaluating the Clinical Abilities and Other Skills of this Applicant?

Kroll Background America, Inc. searched the public record source for the above listed information limited to the stated searched period. The records are differentiated at the source by one or all of the following identifiers: name, date of birth, social security number, race and/or gender. The accuracy of the results may be affected without one or more of these identifiers.