Before You Go: Critical Women's Health Resources 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Provider Name and Provider Type in the designated fields. This information is crucial for identifying your professional credentials.
3. Fill in the Assigned MTF, Market/Region/SSO, Rank/Grade, DOD ID, and Specialty. Ensure accuracy as these details are essential for processing your reimbursement request.
4. In the 'Place of Duty within the MTF' section, specify where you are stationed. This helps clarify your operational context.
5. Clearly articulate the reasons for requesting reimbursement of licensure fees in the provided space. Be specific about how state restrictions impact your federally authorized clinical functions.
6. Review and complete the attestation statement regarding your licensing status and responsibilities. This ensures compliance with federal regulations.
7. Sign and date the application at the bottom to validate your request before submission.

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