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STATE OF MAINE BOARD OF DENTAL PRACTICEREPLACEMENT LICENSE REQUEST LICENSEE INFORMATION (please print) FULL LEGAL NAMEFIRSTMIDDLE INITIAL HAS YOUR NAME CHANGED? YES IF YES, NAME AS IT APPEARS ON LICENSE:
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phm - replacement licensepub refers to the form used to request a replacement license for a personal health record management system.
Any individual or organization that needs to replace a lost or damaged license for their personal health record management system.
The phm - replacement licensepub form must be completed with the necessary information such as personal details, reason for replacement, and any supporting documentation.
The purpose of phm - replacement licensepub is to provide individuals or organizations with a replacement license for their personal health record management system.
The information required on phm - replacement licensepub includes personal information, reason for replacement, and any supporting documentation.
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