Get 1139a Form

The 1139a Form, used for psychiatry and psychology credentialing, requires careful attention to detail. This guide will walk you through the process of completing the form online, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to complete the 1139a Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name in the designated fields: first, middle, and last. Ensure each name is accurately spelled to maintain professionalism.
3. Next, provide your business address, including the street number, suite (if applicable), city, state or country, and zip code.
4. Indicate your place of birth, telephone number, and birth date in the specified format (month/day/year), ensuring all details are clear and correct.
5. Answer the question regarding your residency in Hawaii by selecting 'Yes' or 'No' and specify how long you have lived there.
6. Respond to the questions regarding certification or licensing in other states, including any denials or suspensions of your certificates.
7. List your educational background, starting with the most recent institution. Include your major course of study, date of graduation, and degree conferred.
8. Detail your experience by listing your most recent positions along with the duties you performed, including the name and address of each employer.
9. Confirm any relevant certifications such as a diplomat certificate from the American Board of Examiners, your membership with the American Psychological Association, and any hospital privileges or clinic affiliations.
10. Review all entries for accuracy before signing and dating the form at the bottom, ensuring that your signature reflects your professional identification.
11. Finally, save your changes, download a copy for your records, or print the completed form to submit as required.

Complete the 1139a Form online today to ensure a smooth credentialing process.