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How to use or fill out dh 1479 form with our platform
- Click ‘Get Form’ to open the dh 1479 form in the editor.
- In Section I, enter your licensed health care provider information, including your name and medical license number. Ensure that only licensed providers under Chapters 458, 459, or 464, F.S., complete this section.
- Provide a contact name and telephone number for any inquiries from Florida SHOTS personnel regarding this agreement.
- Move to Section II and fill out all required fields for each facility where you practice. This includes the organization name, type of facility, address, city, state, zip code, phone number, and fax number.
- In Section III, review the submission instructions carefully. Once completed, mail or fax the form to the Florida Department of Health at the provided address or fax number.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2007 | 4.8 Satisfied (265 Votes) |
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