Nevada Standard Application Form - Fill Online, Printable 2025

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The document is a Uniform Credentialing Form from the Nevada Department of Business and Industry, Division of Insurance, intended for recredentialing healthcare providers. It collects comprehensive personal, professional, and educational information necessary for evaluating a provider's qualifications for participation in health plans and healthcare organizations in Nevada. The form includes sections on personal data, office information, professional licenses, malpractice insurance history, continuing education, peer references, and a practitioner questionnaire regarding any disciplinary actions or legal issues. It also contains an authorization section allowing the release of information related to the applicant's credentials.

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