Get Mi Lara Certification Of Appointment To A Michigan Training Hospital For A Medical Doctor License 2021-2026

The MI LARA Certification Of Appointment To A Michigan Training Hospital For A Medical Doctor License is an essential document for medical professionals seeking to gain licensure in Michigan. This guide provides a clear, step-by-step approach to help users navigate the online form efficiently and effectively.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by checking the appropriate box indicating whether you are applying for initial licensure or renewing an active license.
3. Complete the applicant information section by entering your first name, middle name, last name, date of birth in MM/DD/YYYY format, and the last four digits of your Social Security number.
4. If applicable, list your Michigan Educational Limited License number for renewal purposes.
5. The remainder of the form must be completed by the Director of Medical Education. They will fill in the name and address of the training hospital, including city, state, and zip code.
6. If applicable, include the ACGME/AOA/CPME program number associated with the training program.
7. Under the certification and signature section, the Director of Medical Education certifies the appointment by specifying the clinical area of the program. This field should be completed with the program name.
8. The Director of Medical Education must check the appropriate box reflecting the accreditation status of the training program—MD Only, DO Only, or Podiatry Only.
9. The form must also include the signature of the Director of Medical Education, their printed or typed name, and the date.
10. If the hospital does not have an official seal, this must be indicated in the designated area.
11. Once all information is correctly filled out, save the changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth application process!