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Mandatory practitioner profile questionnaire

Mandatory practitioner profile questionnaire 2026

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The document outlines the Mandatory Practitioner Profile Questionnaire required by the Tennessee Department of Health for licensed health care providers, as mandated by the Health Care Consumer Right-to-Know Act of 1998. It details the information that practitioners must submit, including personal data, education, certifications, disciplinary actions, and malpractice claims. The questionnaire must be completed and submitted before licensure is granted, with updates required within 30 days of any changes. Failure to comply may result in delays or disciplinary actions.

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Click ‘Get Form’ to open the mandatory practitioner profile questionnaire in our editor.
Begin with Part I, 'Practitioner Data'. Fill in your license number and profession. If you don’t have a license number yet, leave it blank. Provide your social security number for internal tracking; it will not be published.
Complete your primary practice address. If this is also your home address and you wish it to be public, check the appropriate box.
In Part II, list your graduate and postgraduate medical education chronologically. Ensure to exclude any continuing education courses.
Proceed to Part III for specialty board certifications. Indicate if you hold any certifications from recognized boards and provide details as required.
Continue through each section, answering all questions accurately. For any 'yes' responses in disciplinary actions or criminal offenses, provide detailed explanations as instructed.
Once completed, review all entries for accuracy before submitting the form via mail as specified in the instructions.

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Versions	Form popularity	Fillable & printable
2013	4.9 Satisfied (58 Votes)
2009	4.3 Satisfied (49 Votes)

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Can physician assistants practice independently in Tennessee?

A: Yes, unless you are supervising a PA who holds a temporary license pursuant to TCA 63-19- 105(a)(2). PAs with a temporary license must be supervised by an on-site physician at all times. Otherwise, supervision does not require the constant and continuous presence of a supervising physician.

Can a PA practice independently in TN?

How is nursing regulated in Tennessee?

The Board of Nursing was created in 1911 by an act of the State Legislature and signed into law by former Governor Ben W. Hooper. The boards mission is to safeguard the health, safety and welfare of Tennesseans by requiring that all who practice nursing within this state are qualified and licensed to practice.

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Can a non physician own a medical practice in Tennessee?

First, there is no statutory provision that would exempt such licensed allied health care providers from the corporate practice of medicine doctrine. No statute countenances such ownership by non-physicians of a professional practice that includes the provision of medical services.

Is Tennessee a full practice state?

Tennessee is one of 11 states with the highest level of restrictions for advanced practice registered nurses (APRNs) nurse practitioners, nurse midwives, nurse anesthetists and clinical nurse specialists requiring them to work under collaborative practice agreements with a physician.

Can a nurse practitioner have their own practice in Tennessee?

While Tennessee does require NPs to be supervised by a physician, these rules are lax compared to many other states.

Can you own a medical practice without being a doctor in Texas?

In the most simple terms, if you do not have the proper licensing and credentials to practice medicine, you cannot operate a medical facility or employ physicians in the state of Texas. This doctrine applies to corporations, entities, and any generally classified non-physician.