Certification 2011 form: Fill out & sign online

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Click ‘Get Form’ to open the certification 2011 form in the editor.
Begin by filling out the 'Primary Office Information' section. Enter your name, address, city, state, zip code, professional designation, work phone number, and email address. Ensure all fields are completed accurately.
Provide your primary DEA number and state license number. If you have additional DEA numbers or state licenses, list them in the designated fields.
In the 'Hospital Affiliation Information' section, input details for your primary hospital affiliation first. If you have more than four affiliations, check the box provided.
Review the certification statements carefully. Confirm your understanding of the requirements regarding Tikosyn therapy and ensure you agree to all terms before signing.
Finally, add your signature and date at the bottom of the form. Once completed, save your document and follow instructions to submit it via mail or fax.

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