Get Physical Agent Modality Certification Application - Nebraska Health ...

Filling out the Physical Agent Modality Certification Application for Nebraska Health is a crucial step for practitioners seeking certification in physical agent modalities. This guide provides comprehensive, step-by-step instructions to help you navigate the application process with ease.

Follow the steps to complete your application online.

1. Click the ‘Get Form’ button to obtain the application form and open it in your chosen online editor.
2. Begin by filling out Section A with your personal information. Ensure your legal name is entered accurately, along with any other names you may go by. Include a reliable mailing address, as all correspondence will be sent to this address.
3. Next, provide your date and place of birth, and check the appropriate box regarding your Social Security Number, Alien Registration Number, or Form I-94 number, if applicable.
4. In Section B, enter your Nebraska License Number and confirm whether you have administered physical agent modalities prior to this application. If you answer 'yes,' indicate the number of days you have provided these modalities in Nebraska.
5. Move on to Section C, where you will specify the categories of physical agent modalities for which you are applying. Make sure to tick all applicable boxes and choose the means of certification you are pursuing.
6. Complete Section D, disclosing any convictions or licensure actions. It is essential to provide thorough explanations if you answer 'yes' to any of the questions in this section.
7. In Section E, you will attest to your citizenship or immigration status. Check the appropriate box to confirm your status and affirm the accuracy of your application statements.
8. After completing all sections, ensure that you have gathered and attached any required documentation as listed in the note section. This includes proof of age, citizenship, and if necessary, any documentation related to convictions.
9. Finally, review your application thoroughly, sign and date it, and ensure that all requested documents are included before submitting.

Begin your application process online today to ensure timely certification!