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Get DA 4691-1 2004-2024

Inical privileges and staff appointment. To support the credentialing and privileging processes. A copy of this form will be retained in provider credentials file. Information may be provided to certain civilian institutions, the Federation of State Medical Boards of the U.S., State Licensure Authorities, and other appropriate professional regulatory bodies. Disclosure of information requested is voluntary. However, failure to provide the required information may interfere with the timely granti.

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