Get Dhs 1139a Instructions 2010-2025

Filling out the DHS 1139A Instructions is essential for health care providers specializing in psychiatry and psychology. This guide provides a straightforward approach to completing the form accurately online, ensuring all necessary information is included.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the DHS 1139A form and open it in your preferred editing interface.
2. Enter your full name in the designated field. Ensure that your name is spelled correctly as it will appear on official documents.
3. Provide your business address. This should be the address where you primarily conduct your practice.
4. Fill in your place of birth and date of birth. Use the format requested in the form to avoid any errors.
5. Indicate whether you are a Hawaii resident. This information is crucial for your application.
6. Confirm your certification and licensing status. If applicable, include the state of certification.
7. State if you have ever been denied certification or licensing. If yes, list the state(s) associated with the denial.
8. Provide details regarding any suspension or revocation of your license. If applicable, attach a statement explaining the circumstances.
9. Outline your educational background, including institutions attended and degrees earned.
10. Detail your relevant experience in the field of psychiatry or psychology.
11. Indicate if you hold an American Board Certification for your specialty. If yes, provide the date of certification.
12. Answer whether you are a member of the American Psychological Association (APA). If yes, specify the type of membership.
13. State if you have hospital privileges. This is an important aspect of your credentials.
14. Indicate any affiliations with clinics. This information helps to establish your professional connections.
15. Confirm if you are a private practitioner. This should be clearly indicated in your response.
16. Once all sections are completed, you can save changes, download, or print the form for submission.

Complete your DHS 1139A form online today to ensure a smooth application process.