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The document is the KAPER-1 (03/2007) form, specifically Part B, Section 2, which outlines the application process for health care providers seeking reappointment for privileges at health care facilities in Kentucky. It includes instructions for completing the uniform application for re-evaluation (recredentialing), required attachments such as licenses and insurance proof, personal identification data, professional employment history, peer references, and a certification section. The form emphasizes the need for accurate information and consent for background checks related to the provider's qualifications and professional conduct.

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