Bronson Health Medical Staff/APP Intake Form 2019 free printable template
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Medical Staff / APP Intake Form Provider Name: Provider Email: Provider Telephone: NPI #: Specialty: Provider Gender: APP Provider Supervising Physician: Please check the appropriate box below for
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How to fill out Bronson Health Medical Staff/APP Intake Form
01
Begin by gathering your personal information, including your name, address, phone number, and email.
02
Provide your social security number and date of birth in the designated fields.
03
Fill out your medical education details, including schools attended, degrees obtained, and any certifications.
04
List your medical licensing information, including license numbers and states of issuance.
05
Include details about your work history, detailing previous positions held, responsibilities, and duration of employment.
06
Fill in any hospital affiliations or memberships in professional organizations.
07
Disclose any malpractice history or disciplinary actions in the required sections.
08
Provide references by including their contact information and professional relationship to you.
09
Review the form for any errors or omissions before submission.
10
Sign and date the form where indicated.
Who needs Bronson Health Medical Staff/APP Intake Form?
01
Healthcare professionals seeking to join the Bronson Health medical staff.
02
Advanced Practice Providers (APPs) looking to practice within the Bronson Health system.
03
Individuals applying for privileges at Bronson Health facilities.
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What is Bronson Health Medical Staff/APP Intake Form?
The Bronson Health Medical Staff/APP Intake Form is a document used to collect essential information from medical staff and advanced practice providers (APPs) at Bronson Health for credentialing and onboarding purposes.
Who is required to file Bronson Health Medical Staff/APP Intake Form?
All new medical staff members and advanced practice providers (APPs) seeking to join Bronson Health are required to file the Bronson Health Medical Staff/APP Intake Form.
How to fill out Bronson Health Medical Staff/APP Intake Form?
To fill out the Bronson Health Medical Staff/APP Intake Form, individuals should provide accurate personal information, professional credentials, work history, and any other required details as specified in the form instructions.
What is the purpose of Bronson Health Medical Staff/APP Intake Form?
The purpose of the Bronson Health Medical Staff/APP Intake Form is to gather necessary data for the credentialing process, ensuring that medical staff and APPs meet the institution’s standards for quality and care.
What information must be reported on Bronson Health Medical Staff/APP Intake Form?
The information that must be reported on the Bronson Health Medical Staff/APP Intake Form includes personal identification details, professional qualifications, work history, licenses, certifications, and any disciplinary actions or malpractice claims.
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