Get Tn Form Ph-4310

This guide provides users with a clear and straightforward process for completing the TN Form PH-4310 online. It covers each section of the form in detail, ensuring that users can effectively communicate the appointment of an Interim Medical Director for a pain management clinic.

Follow the steps to complete the TN Form PH-4310 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the name of the clinic in the designated field. Ensure you print this information legibly to avoid processing delays.
3. Provide the license number of the clinic. Double-check the number for accuracy.
4. Fill out the clinic's address, including street, city, state, and zip code. Take care to format this information properly.
5. Input the name of the current Medical Director. This section is crucial for the continuity of the clinic's operations.
6. Record the Tennessee license number of the current Medical Director to validate their credentials.
7. Write the name of the Interim Medical Director who is being appointed.
8. Enter the Tennessee license number of the Interim Medical Director. This ensures compliance with state regulations.
9. Select one of the options that describe how the Interim Medical Director qualifies as a pain management specialist. Be sure to attach the required supporting documentation for the chosen qualification.
10. Print the name of the person completing the form, followed by the date of completion.
11. Collect the signature of the person filling out the form, confirming their authority and responsibility.
12. Indicate the position of the person completing the form to clarify their role within the clinic.
13. Once all sections are filled out, save changes, download, print, or share the form as required.

Complete your TN Form PH-4310 online today to ensure timely notification of your Interim Medical Director appointment.