Get Hi Hwmg Cr E-03-1 2018

Filling out the HI HWMG CR E-03-1 credentialing application is an essential step for practitioners seeking membership in the Hawaii Western Management Group. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin with the 'Practitioner Information' section. Fill in your last name, first name, middle initial, suffix if applicable, and date of birth. Provide your taxpayer identification number and social security number, and indicate your citizenship status.
3. Move on to the 'Credentialing Contact Information' section. Enter your preferred contact method, along with the related contact details, including phone number, email address, and mailing address.
4. Fill in the 'Professional License' section. List all relevant professional licenses, including the state, license number, date issued, and validity period.
5. Complete the 'Specialty/Sub-Specialty Board Certification(s)' section. Indicate your primary specialty, certifying board, and provide details regarding board certification status.
6. In the 'State Controlled Substance and Federal Drug Enforcement Administration Certification' section, provide the required certification numbers and validate whether they are approved for all schedules.
7. Detail your 'Professional Liability Insurance' coverage, including the insurance carrier, policy number, and amount of coverage per occurrence.
8. Continue with the 'Professional Education and Training' section. Document your educational history, including internships, residencies, fellowships, and any other relevant training.
9. Complete the 'Clinical Employment/Practice History' section, listing all relevant clinical experiences in chronological order.
10. In the 'Malpractice Litigation and Professional Complaints' section, indicate if you have faced any lawsuits or complaints, providing details as necessary.
11. Answer the 'Disclosure Questions' honestly, attaching separate sheets if required to explain any affirmative answers.
12. Review and sign the 'Standard Authorization, Attestation, and Release' section to certify that the provided information is accurate.
13. Finally, attach all required documents as indicated in the 'Evidence of Credentials Checklist.' Review your Application for any omissions before submission.
14. Once you have completed the form, you can save your changes, download it for your records, print a hard copy, or share it as needed.

Start filling out the HI HWMG CR E-03-1 online today to ensure your credentialing process is complete.