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Minnesota Uniform Credentialing Application InitialPhysician/Dentist/Allied Health ProfessionalApplicant Name: Last First Middle Suffix TitleCREDENTIALING CONTACT INFORMATION Name Phone Number Address
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How to fill out please mark all non-applicable

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To fill out the form, follow these steps:
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Read the instructions carefully.
03
Provide accurate information in each section.
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Mark 'N/A' or 'non-applicable' for any questions that do not apply to you.
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Double-check your answers for any errors or missing information.
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Sign and date the form if required.
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Submit the completed form as instructed.
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