Dhs1139a instructions credentialing form 2026

1. Click ‘Get Form’ to open the DHS 1139A in the editor.
2. Begin by entering your name in the designated field. This is a straightforward requirement.
3. Next, provide your business address. Ensure that all details are accurate for proper identification.
4. Fill in your place of birth and birth date. These fields are self-explanatory but crucial for verification.
5. Indicate if you are a Hawaii resident. This information may affect your application process.
6. Confirm your certification and licensing status. If applicable, specify the state of certification.
7. If you have experienced any denial of certification or licensing, list the relevant states.
8. Address any suspensions or revocations of your license by attaching a statement if necessary.
9. Detail your education background as required by the form.
10. Outline your experience in the field, ensuring to highlight relevant positions held.
11. If you hold an American Board Certification for your specialty, provide the date of certification.
12. Indicate whether you are a member of the A.P.A., specifying the type of membership if applicable.
13. List any hospital privileges you currently hold, as this is pertinent to your credentialing process.
14. Finally, mention any affiliations with clinics and confirm if you are a private practitioner.

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