INSTRUCTIONS DHS 1139A (04 08) PSYCHIATRY PSYCHOLOGY CREDENTIALING ATTACHMENT PURPOSE: Form DHS 1139-2026

Definition and Purpose of Form DHS 1139A

Form DHS 1139A, titled the "Instructions DHS 1139A (04 08) Psychiatry Psychology Credentialing Attachment," is a critical document utilized within the health care sector. Specifically, it serves as a credentialing attachment required by health care providers who are focused on psychiatry or psychology to certify that their qualifications meet the requisite standards. This form plays an essential role in ensuring that practitioners possess the appropriate credentials, such as educational background, professional experience, and affiliations, necessary to deliver informed and legal psychological services.

Steps to Complete Form DHS 1139A

Successfully completing Form DHS 1139A involves a series of meticulous steps designed to capture the comprehensive credentials of a psychiatry or psychology professional.

1. Provide Personal Information: Enter your full name, address, and contact details. Ensure accuracy as these details form the base of your credential profile.

2. Certification Status: Indicate your current certification status, including any professional licenses or certifications pertinent to psychiatry or psychology.

3. Educational Background: List all relevant educational qualifications. Include institution names, dates of attendance, and degrees obtained.

4. Professional Experience: Detail your work experience in the field, specifying roles, responsibilities, and duration of each position held.

5. Affiliations: Document any affiliations with professional organizations, including memberships or board positions.

6. Review and Submit: Once all sections are completed, review for accuracy, ensure all necessary documentation is attached, and submit via the specified method.

Who Typically Uses Form DHS 1139A

Form DHS 1139A is predominantly utilized by licensed professionals in the fields of psychiatry and psychology. These include clinical psychologists, psychiatrists, and counseling psychologists who are seeking credentialing or credential renewal within hospitals, clinics, or private practices. Additionally, administrative staff within human resources departments of such organizations may use this form to verify and maintain staff credentials.

Key Elements of Form DHS 1139A

Understanding the key elements of Form DHS 1139A is crucial for accurate completion.

• Personal Details Section: This requires basic personal identifiers but must be accurate for official record keeping.
• Professional Credentials: Detailed documentation of certifications and licensures ensures that the practitioner meets state and federal requirements.
• Education and Affiliations: Enumerating all educational achievements and affiliations provides a complete professional profile to credentialing authorities.
• Declaration Section: By signing this section, practitioners affirm the truthfulness and completeness of the provided information.

State-Specific Rules for Form DHS 1139A

While Form DHS 1139A maintains its fundamental structure, some state-specific regulations may influence additional requirements or variances in the information provided. Practitioners should check with their state’s Department of Health Services to confirm any additional credentialing documentation that might be necessary. For example, some states may require additional proof of continuing education credits or state-specific accreditation.

Legal Use of Form DHS 1139A

Legally, Form DHS 1139A is recognized as a binding document that asserts a professional’s credentials within the field of psychiatry or psychology. The form’s completion and submission must comply with both federal and state regulations governing healthcare professionals. Misrepresentation or false information can result in sanctions, revocation of licenses, or legal actions against the individual.

Submission Methods for Form DHS 1139A

There are various methods for submitting Form DHS 1139A. While some entities may accept digital submissions via secure online portals, others may require physical mail submissions. Practitioners must verify the preferred method of submission with their employing institution or the state's credentialing authority to ensure compliance with specific communication protocols.