Loading
Get Hfs 3411c N 3 06 Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Hfs 3411c N 3 06 form online
This guide provides a comprehensive overview of how to complete the Hfs 3411c N 3 06 form online. By following the steps outlined here, you will be able to fill out the form accurately and efficiently.
Follow the steps to fill out the Hfs 3411c N 3 06 form online
- Click the 'Get Form' button to obtain the Hfs 3411c N 3 06 form and open it in your online editing tool.
- Begin by filling out the provider information section. Enter your last name, first name, and middle initial in the designated fields. This information is essential for accurate identification.
- Provide your provider number in the next field. This number is typically assigned to you by the Department of Healthcare and Family Services.
- Complete your office address by entering the full address, including city, state, and zip code. This information is necessary for correspondence.
- Enter your office phone number. Make sure to include any area codes. Additionally, provide an after-hours phone number if applicable.
- Fill out your license number and the state where you are licensed to practice. This confirms your credentials.
- Include your fax number in the appropriate section. This is often used for communication with the Department.
- In the APN certifications section, check all applicable certifications such as Certified Nurse Midwife, Certified Registered Nurse Anesthetist, or Certified Nurse Practitioner.
- If relevant, specify your specialty areas as a nurse practitioner or clinical nurse specialist.
- List the collaborating physician's name, address, and their FEIN (Federal Employer Identification Number) where requested.
- If you are a Certified Registered Nurse Anesthetist not required to maintain an agreement, provide the hospital's name and address, along with the phone number.
- In the certification section, review the statements, then enter your signature and the date to confirm the information is accurate.
- Once all fields are completed, save your changes. You can then download, print, or share the form as needed.
Take the next step and complete your forms online today.
To acquire full practice authority in Illinois, you must complete a qualifying graduate program and obtain the necessary clinical experience.Next, you'll apply to the Illinois Department of Financial and Professional Regulation. To facilitate this process, be sure to fill out the Hfs 3411c N 3 06 Form accurately, as this will help demonstrate your qualification for independent practice.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.