Get Maine Professional Staff Application Form

Filling out the Maine Professional Staff Application Form online is a critical step in your credentialing process. This guide provides a clear and structured approach to assist you in completing the form accurately and effectively.

Follow the steps to successfully complete the application form.

1. Click ‘Get Form’ button to obtain the Maine Professional Staff Application Form and open it in your preferred online editing tool.
2. Review the general information section carefully. Enter your last name, first name, middle initial, degree, place of birth, and contact details including home address, phone, and email. Ensure this information is accurate, as it will be used for verification purposes.
3. Complete the specialty and board certification section, indicating your initial certification date and whether you are pursuing further certification. Include details of your specialty certification.
4. Provide your educational history, listing both undergraduate and professional education. Include the institution name, degree awarded, and dates attended.
5. Document your hospital affiliations chronologically, starting with your primary hospital. Include the institution's name, department, position, and relevant dates.
6. List your work history, covering all professional activities. Explain any gaps longer than 60 days in your chronology on a separate page.
7. Include three professional references, ensuring they have observed your clinical abilities. Collect their names, phone numbers, and addresses, along with how they know you professionally.
8. Complete the health information section honestly, answering questions about your physical and mental ability to perform required functions. Any explanations required should be noted on a separate sheet.
9. Fill in the licensing section accurately, listing all current and past licenses, including their type, expiration dates, and status.
10. Provide information on your professional liability history, including any previous claims or insurance details. This information is crucial to your credentialing.
11. Complete any additional information required, ensuring every question is answered. If necessary, provide explanations on additional sheets.
12. Before submitting, review your application for accuracy and completeness. Ensure that all required documents are attached as per the checklist.
13. Finally, save changes, download the completed application, print it for your records, and share it with the relevant organizations as necessary.

Start completing your application online to ensure a smooth credentialing process.