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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'NAME OF PROVIDER' field, ensuring you include your last name, first name, and middle initial.
Fill in your rank/grade and date of birth in the respective fields. Use the format YYYYMMDD for the date.
Provide the name and address of your medical or dental facility in the 'MEDICAL/DENTAL FACILITY' section.
For questions 6a to 6n, place a check (X) in the column that corresponds to your answer. Remember, any 'YES' answers must be explained in block 7.
In block 7, clarify any 'YES' responses from question 6 by noting the item number and providing detailed explanations.
Complete blocks 8 through 10 regarding health status, malpractice insurance, and clinical privileges as required.
Finally, certify the information by signing and dating at the bottom of page two before saving or exporting your completed form.

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