Get Greater Arizona Central Credentialing Program Form

This guide provides a comprehensive overview of how to accurately complete the Greater Arizona Central Credentialing Program Form online. Following these steps will help ensure all necessary information is submitted correctly and efficiently.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the date in the specified field at the top of the form. Ensure it is correctly formatted.
3. Complete the application section for allied health practitioner appointment. Indicate your practitioner classification by selecting from the provided titles.
4. Proceed to fill in your personal data under Section I. Ensure all fields, such as name, address, phone number, and citizenship, are filled without leaving spaces blank.
5. Continue with Section II by entering your current practice information, including your primary office details and any additional locations.
6. In Section III, list all current professional licenses/registrations. Attach copies of these licenses as required.
7. In Section IV, provide details about your education. List all relevant degrees and ensure the data is complete without referencing a CV.
8. Section V requires you to input your postgraduate training, including institution names and types of training.
9. Address any military or public health service experience in Section VI, and provide documentation as needed.
10. In Section VII, detail your work experience for the past five years, and be sure to include verification contacts for each employer.
11. If applicable, account for any gaps in employment in Section VIII and provide explanations where necessary.
12. List your healthcare affiliations in Section IX and include reasons for any terminations.
13. In Section X, provide any certifications and attach relevant documentation.
14. Fill out the professional liability insurance information in Section XI, and attach your current insurance certificate.
15. Under Section XII, provide the details of your professional references, ensuring they meet the requirements outlined.
16. Complete any additional questions under Sections XIII to XVI regarding your health status and attestations.
17. Review the release and statement of applicant section carefully, and ensure you understand the terms before signing.
18. Final steps include saving your changes, downloading, printing, or sharing the form as necessary.

Start completing your Greater Arizona Central Credentialing Program Form online now!