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REFERRING INSTITUTION Name: Pathologist: Pathologist NPI#: Email: Address: Phone: City, State, Zip: FAX: PATIENT INFORMATION Name (Last, first, middle): Outside MR #: Gender: DOB (MM/DD/YYY): SSN:
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How to fill out hospital-based practitioner profile

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Step 1: Access the hospital-based practitioner profile form on the hospital's website.
02
Step 2: Provide your personal information such as name, contact details, and address.
03
Step 3: Fill in your educational background, including medical degrees, certifications, and specializations.
04
Step 4: Include your work experience, mentioning previous hospitals or healthcare facilities you have worked at.
05
Step 5: Mention any publications or research work you have contributed to in the medical field.
06
Step 6: Provide details of any professional memberships or affiliations you have with medical associations.
07
Step 7: Include any additional information or credentials that may be relevant to your hospital-based practice.
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Step 8: Review the completed profile form for accuracy and completeness.
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Step 9: Submit the filled-out profile form online or follow the instructions for physical submission.

Who needs hospital-based practitioner profile?

01
Hospital-based practitioners, including doctors, nurses, and other medical professionals, need to fill out a hospital-based practitioner profile.
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Medical students or residents seeking opportunities or placements in hospitals may also be required to complete a hospital-based practitioner profile.
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Hospital-based practitioner profile is a profile that includes information about a practitioner who works within a hospital setting.
Hospital-based practitioners are required to file their profile.
Hospital-based practitioners can fill out their profile online or through a paper form provided by the hospital.
The purpose of the hospital-based practitioner profile is to ensure that the hospital has accurate information about the practitioners working within its facility.
Information such as name, contact information, specialty, license number, and any relevant certifications must be reported on the profile.
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