Get Or Omb Verification Of Practice Employment Staff Membership Md/do/dpm Licensure 2015

Filling out the OR OMB Verification of Practice Employment Staff Membership MD/DO/DPM Licensure form is a crucial step for professionals in the medical field. This guide provides a clear and comprehensive overview to help you successfully complete the form online.

Follow the steps to complete your licensure form online.

1. Use the ‘Get Form’ button to access the form and open it in an online editor.
2. Fill in the upper portion of the form with your last name, first name, any other names you have been known by, middle name, and date of birth in the format mm/dd/yy.
3. Provide the name of the hospital, clinic, or facility where you were associated during your employment, and select your type of association from the provided options: Employee, Staff Member, Locum Tenens, Emergency Room, or Instructor.
4. Enter the last four digits of your Social Security number and the dates of your association with the facility in the mm/dd/yy format for both the 'FROM' and 'TO' fields.
5. Acknowledge and authorize the release of all pertinent information by signing the document and adding the date of your signature.
6. Once you complete the upper section, send the form directly to the hospital, clinic, or facility where you were employed.
7. Instruct the hospital or clinic to fill out the lower portion of the form. This includes checking the appropriate type of association.
8. The facility must provide the dates of association and answer any questions regarding unusual circumstances related to your association.
9. The facility should complete the signature and print name, affix the institutional seal (if applicable), and provide their contact information.
10. Ensure the completed form is returned directly to the Oregon Medical Board in an institution envelope, as faxed responses will not be accepted.
11. After completing the process, you can save changes to the form, download it for your records, print it out, or share it as necessary.

Complete your OR OMB Verification of Practice Employment Staff Membership MD/DO/DPM Licensure form online today to ensure your licensure is processed efficiently.