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Print Form State of California - California Health and Human Services Agency Office of Statewide Health Planning and Development CALIFORNIA CABG OUTCOMES REPORTING PROGRAM Healthcare Information Division Healthcare Outcomes Center 400 R. Street Room 250 Sacramento California 95811 FAX 916 445-7534 Surgeon Certification Form OSH-CCORP 415 Revised 06/09 Surgeon s Name First Middle Initial Last California Physician License Number Hospital Name Facil...
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How to fill out surgeon certification form
How to fill out Surgeon Certification Form
01
Obtain the Surgeon Certification Form from the relevant authority or institution.
02
Fill in your personal information, including your name, address, and contact details.
03
Provide your medical license number and specialty information.
04
Document your educational background and training relevant to the surgical field.
05
List your professional experience, including hospitals or clinics where you've worked.
06
Sign and date the form to certify that all provided information is accurate.
07
Submit the completed form to the designated office or online portal as instructed.
Who needs Surgeon Certification Form?
01
Surgeons seeking professional certification for practice.
02
Medical institutions requiring proof of a surgeon's qualifications.
03
Insurance companies needing verification of a surgeon's credentials.
04
Patients wanting to ensure their surgeon is certified and qualified.
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What is Surgeon Certification Form?
The Surgeon Certification Form is a document that certifies a surgeon's qualifications and capability to perform specific medical procedures.
Who is required to file Surgeon Certification Form?
Surgeons who are seeking to perform certain surgical procedures or who are applying for privileges in a hospital or medical facility are typically required to file the Surgeon Certification Form.
How to fill out Surgeon Certification Form?
To fill out the Surgeon Certification Form, the surgeon must provide personal information, professional qualifications, a list of certifications, relevant training, and clinical experience, as well as sign and date the form.
What is the purpose of Surgeon Certification Form?
The purpose of the Surgeon Certification Form is to ensure that surgeons meet the required standards and qualifications to safely perform surgical procedures, thus protecting patient safety and healthcare quality.
What information must be reported on Surgeon Certification Form?
The information that must be reported on the Surgeon Certification Form includes the surgeon's name, medical license number, educational background, residency and fellowship training, board certifications, and relevant surgical experience.
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