Get the free Ancillary Practitioner Data Form - Chiropractor

TUFTS ASSOCIATED HEALTH MAINTENANCE ORGANIZATION, INC. TOTAL HEALTH PLAN, INC. ANCILLARY PRACTITIONER DATA FORM CHIROPRACTOR Please fax to 6179729591 or mail to Tufts Health Plan, ATTN: Credentialing

How to fill out ancillary practitioner data form

1. Before filling out the ancillary practitioner data form, make sure you have all the necessary information and documents ready. This may include your personal contact details, educational qualifications, professional certifications, and any relevant work experience.
2. Begin by providing your full name, including any suffixes or titles, in the designated section of the form. This will help identify you correctly.
3. Fill in your professional address, including the street name, city, state, and postal code. It is important to provide accurate contact information so that you can be reached if needed.
4. Include your professional email address and phone number. These details will be used to communicate with you regarding any updates or changes related to your ancillary practitioner status.
5. Indicate your field of expertise or specialization. This may include areas such as chiropractic care, acupuncture, physical therapy, or any other relevant discipline.
6. Provide information about your educational background. Include the name of the institution(s) you attended, the degrees or certifications you obtained, and the dates of completion. If you have multiple degrees or certifications, provide details for each of them.
7. Mention any professional licenses or registrations you hold. This could include state or national licenses that are required to practice as an ancillary practitioner in your area.
8. If applicable, describe any relevant work experience you have gained in the field. This may include previous employment, internships, or volunteering experiences. Provide details such as the name of the organization, your job title, and the duration of your employment or involvement.
9. If requested, you may need to attach copies of supporting documents such as your resume, educational transcripts, professional licenses, or reference letters. Carefully review the instructions provided on the form to ensure you include all required attachments.
10. Once you have completed filling out the form, review it for any errors or missing information. Double-check that all the details provided are accurate and up to date.

Who needs ancillary practitioner data form?

1. Healthcare professionals who work as ancillary practitioners such as chiropractors, acupuncturists, physical therapists, massage therapists, or any other related disciplines.
2. Students or individuals seeking to pursue a career in ancillary healthcare professions may also need to fill out this form as part of their application or registration process.
3. Healthcare organizations, regulatory bodies, or government agencies that require comprehensive data on ancillary practitioners for licensing, accreditation, or monitoring purposes.

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What is ancillary practitioner data form?

The ancillary practitioner data form is a document used to collect information about ancillary practitioners, such as nurse practitioners or physician assistants.

Who is required to file ancillary practitioner data form?

Healthcare facilities and organizations are required to file the ancillary practitioner data form.

How to fill out ancillary practitioner data form?

The form can be filled out online or in hard copy with information about the ancillary practitioners working at the facility.

What is the purpose of ancillary practitioner data form?

The purpose of the form is to track and monitor the qualifications and credentials of ancillary practitioners for regulatory compliance and quality assurance.

What information must be reported on ancillary practitioner data form?

Information such as the practitioner's name, license number, area of specialty, and contact information must be reported on the form.