/13) www.michigan.gov/healthlicense MICHIGAN HEALTH PROFESSIONALS – REPORT OF CHANGE IN STAFF PRIVILEGES Section 333.20175 of the Michigan Public Health Code, 1978 PA 368, as amended, provides the criteria for reporting staff changes. Licensee’s First Name: Middle Name: Last Name: Street Address: City: State: Michigan Professional License Number: Period of Time on Facility Staff: FROM: Did the licensee resign? Yes No Zip Code: Type of Licensure (MD, RN, etc.): Telephone Number wi.
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How to fill out the MI LARA/ED-205 online
Filling out the MI LARA/ED-205 form online is an essential step in reporting changes in staff privileges for health professionals in Michigan. This guide will walk you through each section of the form, ensuring you understand the required components and steps to complete the process efficiently.
Follow the steps to fill out the MI LARA/ED-205 online.
- Click the ‘Get Form’ button to access the online version of the MI LARA/ED-205 form.
- Begin by entering the licensee’s first name, middle name, and last name as they appear on their license.
- Next, provide the street address, city, state, and zip code where the licensee resides.
- Enter the Michigan Professional License Number and the period of time the licensee has been on facility staff, specifying the start and end dates.
- Indicate whether the licensee resigned and, if so, specify if the resignation was voluntary or involuntary.
- If applicable, provide details regarding the suspension or termination of the licensee, including specific dates.
- Answer questions about whether the licensee was placed on probation and whether their practice was limited or restricted. If yes, please provide details.
- Describe the circumstances that led to the change in the licensee’s status, including any relevant dates.
- Attach any supporting documentation if available.
- Sign the form, including the date, and provide your printed or typed name, title, facility name, contact information, and fax number.
- After verifying all entered information, save your changes, and select the option to download, print, or share the completed form.
Get started filling out your MI LARA/ED-205 form online today!
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