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Dhs1139a instructions credentialing form 2026
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- Click ‘Get Form’ to open the DHS 1139A in the editor.
- Begin by entering your name in the designated field. This is a straightforward requirement.
- Next, provide your business address. Ensure that all details are accurate for proper identification.
- Fill in your place of birth and birth date. These fields are self-explanatory but crucial for verification.
- Indicate if you are a Hawaii resident. This information may affect your application process.
- Confirm your certification and licensing status. If applicable, specify the state of certification.
- If you have experienced any denial of certification or licensing, list the relevant states.
- Address any suspensions or revocations of your license by attaching a statement if necessary.
- Detail your education background as required by the form.
- Outline your experience in the field, ensuring to highlight relevant positions held.
- If you hold an American Board Certification for your specialty, provide the date of certification.
- Indicate whether you are a member of the A.P.A., specifying the type of membership if applicable.
- List any hospital privileges you currently hold, as this is pertinent to your credentialing process.
- Finally, mention any affiliations with clinics and confirm if you are a private practitioner.
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