Michigan report privileges 2026

1. Click ‘Get Form’ to open the Michigan Report of Change in Staff Privileges in the editor.
2. Begin by entering the licensee's first, middle, and last name, followed by their street address, city, state, and zip code.
3. Input the Michigan Professional License Number and specify the period of time on facility staff by filling in the 'FROM' date.
4. Indicate whether the licensee resigned and if so, specify if it was voluntary or involuntary. Also, note if it was in lieu of termination.
5. Complete sections regarding suspension and termination status. Provide details about any probation periods or practice limitations.
6. Describe the circumstances that led to the change in status, including relevant dates. Attach any supporting documentation as needed.
7. Finally, ensure that you sign and date the form before submitting it back to the appropriate department.

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