STATE OF TENNESSEE DEPARTMENT OF HEALTH RELATED BOARDS 665 MAINSTREAM DRIVE, 2ND FLOOR NASHVILLE, TN 37243 Local (Nashville Calling Area) 615-741-3807 Nationwide (toll free) 1-800-778-4123, ext. 741-3807.
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How to fill out the TN PH 3586 online
The TN PH 3586 form is essential for individuals seeking to become preceptors or establish an Administrator in Training facility in Tennessee. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring all required information is accurately submitted.
Follow the steps to effectively complete the TN PH 3586 form online.
- Click the ‘Get Form’ button to obtain the TN PH 3586 and open it in your preferred online editor.
- Fill in your full name in the designated fields—ensure accuracy for last name, first name, and middle name.
- Provide your business address, including street number, city, state, and zip code.
- Input your telephone number, including the area code, to ensure proper contact information.
- Specify your date of birth and social security number correctly, as these fields are essential for identification purposes.
- Enter your Nursing Home Administrator's license number and the date when it was originally issued in Tennessee.
- Indicate whether your license has been active since its issuance by selecting 'Yes' or 'No.' If 'No', provide detailed information.
- Complete the criteria questions regarding your licensure and practice history, ensuring all statements are true and well documented.
- Fill out the authorization section to permit the release of any necessary health information related to your application.
- Submit the completed form by saving changes. You may choose to download it for personal records, print it, or share it directly with the relevant board.
Complete your TN PH 3586 form online today to begin your journey as a preceptor or Administrator in Training.
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PH #3586. RDA #1786. REV. 09/07. STATE OF TENNESSEE. DEPARTMENT OF HEALTH RELATED BOARDS...
A414 Jane & David Bailey Education Complex, 1126 Volunteer Boulevard, Knoxville, TN 37996;...
011 262 3586. Mon.~ Fri. 08:00am~05:00pm. Israel. Eastronics LTD. 1-800-567000. Sun....
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