Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to acquire the application form and open it for editing.
2. Begin by filling out the personal information section on page 1. Ensure you provide your full name, professional title, and any other names you may have used. Also, include your contact information, date of birth, and Social Security number.
3. Proceed to section I.B where you indicate the practice specialty for which you are seeking affiliation. Choose the appropriate category and provide details if applicable.
4. In section II, enter the primary office practice information. List accepted health plans and specify the type of practice. Essential details include your practice location and contact information.
5. Complete section II.B for cross coverage by listing practitioners who will cover for you, including their specialties and contact details.
6. In section III, provide your medical education history. You must list all relevant institutions attended, including dates and degrees awarded.
7. Fill out IV and V to document your hospital/facility history and work history, ensuring to account for any gaps in your professional timeline.
8. Section VII covers your medical/professional licenses. Include all relevant license numbers, issuance dates, and expiration dates.
9. Complete the board certification section in VIII. If applicable, list certifications and their respective expiration dates.
10. Fill out sections IX through XIV as necessary, relating to references, professional liability, claims history, and health status. Be thorough and honest.
11. Lastly, sign and date the attestation statement at the end of the application. Make sure to save your changes, and you can then download, print, or share the completed form as needed.

Take the next step in your career by completing the Mahp Standard Practitioner Application online today!