Get the free Pmc Physician information form revised August 2010

Professional Medical Corporation 1305 Abbot Road East Lansing, MI 48823 (517) 3361400 FAX: (517) 3364177 Physician Information Form Personal Information: Tax ID#: Last Name: (PLEASE ATTACH W9) First

How to fill out pmc physician information form

How to fill out pmc physician information form:

1. Start by providing your personal information, including your full name, date of birth, and contact information.
2. Next, provide details about your medical education, such as the medical school you attended, the dates you attended, and any degrees or certifications you obtained.
3. Include information about your residency and fellowship training, specifying the institutions where you completed your training and the dates of completion.
4. Provide a list of your current medical licenses with their respective expiration dates and states in which they are valid.
5. Fill out the section regarding your board certification, indicating the specialty or subspecialty in which you are certified and providing the certification board's name and date of certification.
6. If applicable, include any additional certifications or qualifications you possess, such as Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS) certifications.
7. Specify your current employment status, including the name and address of your current employer or practice.
8. Complete the section related to your malpractice insurance, including the name of your insurance carrier, the policy number, and the coverage amounts.
9. Finally, sign and date the form to certify the accuracy of the information provided.

Anyone who is a physician and needs to provide their professional information to a medical credentialing organization or a healthcare facility may need to fill out the pmc physician information form. This form enables healthcare organizations to verify a physician's qualifications and ensure that they meet the necessary criteria to practice medicine. It is commonly required during the initial credentialing process or for recredentialing purposes.

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What is pmc physician information form?

PMC physician information form is a form used to collect information about physicians practicing at a particular PMC (Provider Medical Center) facility.

Who is required to file pmc physician information form?

All physicians practicing at a PMC facility are required to file the PMC physician information form.

How to fill out pmc physician information form?

PMC physician information form can be filled out by providing details such as name, contact information, medical specialty, license number, and any disciplinary actions taken against the physician.

What is the purpose of pmc physician information form?

The purpose of the PMC physician information form is to maintain accurate records of all physicians practicing at a PMC facility for regulatory and compliance purposes.

What information must be reported on pmc physician information form?

The information reported on the PMC physician information form includes the physician's name, contact information, medical specialty, license number, and any disciplinary actions.