Get Michigan Health Professionals Report Of Conviction Form

The Michigan Health Professionals Report Of Conviction Form is essential for reporting felony or misdemeanor convictions related to licensed health professionals. This guide provides clear, step-by-step instructions on how to fill out the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the reporting entity section, including the court's street address, city, state, and zip code.
3. In the defendant name, identifiers, and conviction information section, enter the first name, middle name, last name, previous names (if any), street address, city, state, date of birth, court case number, and conviction date.
4. List the offenses and classify each as a misdemeanor or felony.
5. Check all relevant health care professions in which the defendant is licensed or registered.
6. Complete the submitted by section, including your name, title or position, and telephone number with area code.
7. Review the completed form for accuracy and ensure all fields are adequately filled out.
8. Save the changes you have made, and download, print, or share the form as needed.

Consider completing your documents online for efficiency and accuracy.