Follow the steps to successfully complete your application form.

1. Click ‘Get Form’ button to download the ASDIN Application For HVA Recertification Form and open it in your PDF editor.
2. Begin by entering your identifying information, including your last name, first name, middle name, date of birth, citizenship, and NPI number in the specified fields.
3. Fill in your home address, city, state, and zip code assuming this will be your preferred mailing address for the certificate.
4. Provide your practice information, including the practice name and practice address, along with the corresponding city, state, and zip code.
5. Indicate your current board certification status by selecting the certification board, the date of original board certification, and whether your board certification is current.
6. Detail your medical facility affiliations by listing the names and addresses of your current facilities, including your staff category at each location.
7. In the signature section, confirm that all information is accurate, then provide your signature, date, telephone number, and email address.
8. If applicable, ensure you check the boxes for any advanced procedures you wish to maintain or add. Note the additional fee required for adding procedures.
9. Review the completed application to ensure all required components are included and correct, then save your changes.
10. Submit your completed application and all necessary documents according to the submission guidelines provided in the form.

Complete your ASDIN Application For HVA Recertification Form online today to ensure timely processing.