Get Application - Mississippi State Board - Msbml Ms

The Mississippi State Board of Medical Licensure pain practice application is a crucial document for those looking to register a pain management practice. This guide will help you navigate through filling out the application online with clear instructions tailored for all users.

Follow the steps to complete your application online.

1. Press the ‘Get Form’ button to access the application and open it in your preferred editor.
2. Fill in your primary physician information. Provide your Mississippi medical license number, name as listed on the license, DEA controlled substance registration number, NPI number, federal tax ID number, pain practice address, email address, and phone numbers. If any field does not apply to you, mark it as N/A.
3. Document ownership by selecting the appropriate option (sole proprietor, corporation, partnership, or other) and include the corresponding IRS tax form with the application.
4. Complete the training requirements section, ensuring that you check one of the listed qualifications related to pain management training.
5. Provide the corporate or legal name of the pain practice, physical address, mailing address, and phone numbers for the practice, along with the name and contact details of a designated contact person.
6. Indicate whether your practice performs Level II or III office-based surgery, and if so, state whether it is registered with MSBML.
7. Fill in your practice operating hours accurately. The total hours column will automatically calculate.
8. List all individuals involved in the practice, including owners, employees, and practitioners. Provide their names, roles, and relevant IDs.
9. Answer the eligibility questions concerning medical licensing, disciplinary actions, and any criminal history relevant to prescribing practices.
10. Review all provided information for accuracy. After completing the application, you can save your work, download it, or print it for submission. Ensure that you sign and date the document.

Complete your application online to facilitate your registration process today.