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The Heart Attack Stroke Prevention Center Breaking ground with the Bale/Doneen Method Physician/Provider Information Form Patient s Name Last First Middle Initial Your primary care provider Specialty Last visit Frequency of visits Telephone Fax Address Dental provider Other attending provider 507 S. Washington Suite 170 Spokane WA 99204 Phone 509 747-8000 Fax 509 747-8051 www.

How to fill out physicianprovider information form

How to fill out physicianprovider information form

1. Read the instructions on the physician/provider information form carefully.
2. Make sure you have all the necessary information and documents related to the physician/provider.
3. Start by filling out the personal details section of the form, including name, contact information, and date of birth.
4. Provide the professional information of the physician/provider, such as their specialty, years of experience, and medical license details.
5. Fill out the educational background and training details of the physician/provider.
6. Include any certifications or accreditations the physician/provider may have.
7. Indicate the scope of practice and areas of expertise of the physician/provider.
8. List any affiliations or memberships to professional organizations.
9. Include information about any malpractice claims or disciplinary actions against the physician/provider.
10. Attach any required supporting documents, such as a resume or curriculum vitae.
11. Review the completed form for accuracy and completeness before submitting it.

Who needs physicianprovider information form?

1. Healthcare organizations or facilities that require physician/provider information for credentialing or employment purposes.
2. Insurance companies or third-party payers who need the information to process claims or determine provider eligibility.
3. Government agencies or regulatory bodies that oversee healthcare providers and require updated information.
4. Medical schools or residency programs that collect information for admissions or training purposes.

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