Neuroscience Transfer Resources - Kaleida Health Medical Dental 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and the date at the top of the form. This personal information is essential for identification purposes.
3. Review Part I, which outlines the title and definition of a Certified Nurse Midwife. Familiarize yourself with these terms as they are crucial for understanding your privileges.
4. In Part III, ensure you meet the qualifications listed. If applicable, provide documentation of your certification with the American Midwifery Certification Board.
5. For Part IV, detail your collaborative relationships with licensed physicians as required. Make sure to document this accurately to comply with regulations.
6. In Part V, check the boxes next to each privilege you are requesting. Remember not to use arrows or lines; only checkboxes will be accepted.
7. If any privileges are not granted, provide details in the designated section at the end of Part V. Be clear and concise in your explanations.
8. Finally, sign and date the form at the bottom before submitting it to ensure all information is validated.

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