APPLICATION FOR CERTIFICATION OF ELIGIBILITY - ohsu 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the first field, including your first name, middle initial, and last name.
3. Next, provide your email address and office phone number in the designated fields.
4. Indicate your professional licensure by checking either MD or DO. Enter your BME license number in the provided space.
5. Specify your medical specialty and indicate if you practice OB by selecting 'Yes' or 'No'.
6. Select your professional liability insurance carrier from the list and enter your policy number.
7. Fill out your current primary practice mailing address, including city, county, state, and zip code. Also, indicate the number of hours spent weekly at this location.
8. If applicable, complete the secondary practice mailing address section similarly.
9. Answer whether there has been a change in your practice or liability carrier since January 1 of 2012 and provide the date if applicable.
10. Review the attestation statement regarding serving Medicare and Medicaid patients before signing and dating the form.

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