Loading
Get Tn Ph 3585 2013-2026
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the TN PH 3585 online
The TN PH 3585 form is designed for licensed health care providers in Tennessee to provide necessary information to the Tennessee Department of Health. This guide will walk you through the process of completing and submitting the form online, ensuring you accurately provide the required details.
Follow the steps to complete the TN PH 3585 form online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Part I, fill in your practitioner data. Start with your license number, followed by your social security number, and primary practice address. If your practice address is your home address and you want it published, check the designated box.
- List your supervising physician(s) if applicable, and ensure you provide all necessary contact details including email and web page address.
- In Part II, document your graduate and postgraduate medical education. Mention the institutions attended, degrees obtained, and the dates of graduation. Ensure to list chronologically.
- Part III requires you to provide information on any specialty board certifications you hold. List the certifying body and your specialty.
- Answer all questions in Part IV about faculty appointments, indicating yes or no, with a brief statement for any affirmative responses.
- Complete Part V by detailing your staff privileges at hospitals, if any. Follow the same process in Part VI regarding managed care plans.
- Part VII deals with final disciplinary actions. Carefully indicate any adverse actions taken against you in the past ten years, ensuring all necessary details are included.
- In Part VIII, report any criminal offenses as required. Provide a brief description, including the date and jurisdiction of each offense.
- For Part IX, if applicable, include information on any medical malpractice claims or settlements.
- Finally, complete Part X by filling in any optional information regarding publications or community service activities.
- After completing the form, make sure to save your changes, download the finalized document, and share or print it as needed.
Complete your TN PH 3585 form online today to ensure compliance and a smooth licensure process.
To reach the Tennessee Board of Medical Examiners, you can use the contact information available on their official website. They provide several methods, including phone and email options, for your convenience. Understanding TN PH 3585 can also be beneficial in discussing your inquiries with the board.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.