Loading
Get Dhs 1139a Instructions 2008
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the DHS 1139A Instructions online
Filling out the DHS 1139A form is a crucial step for health care providers specializing in psychiatry and psychology. This guide provides clear, step-by-step instructions to help you complete the form accurately online.
Follow the steps to complete the DHS 1139A form effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter your name in the designated field. Ensure you provide your full legal name as required.
- Fill out your business address. This should include your street address, city, state, and ZIP code.
- Provide your place of birth and birth date. This information helps verify your identity.
- Indicate if you are a Hawaii resident. Selecting 'yes' may require additional documentation.
- Confirm your certification and licensing status. If you have a certification, specify the state where it was issued.
- Inquire about any denial of certification or licensing. If applicable, list the state where the denial occurred.
- State whether your license has ever been suspended or revoked. If so, attach a statement explaining the circumstances.
- Detail your education history, including the names of institutions attended and degrees earned.
- Outline your relevant experience in the field. Include places of employment and positions held.
- If you hold an American Board Certification in your specialty, provide the date of certification.
- Indicate whether you are a member of the American Psychological Association. If yes, specify the type of membership.
- Mention any hospital privileges you hold. Include the name of the hospital and details of your privileges.
- State your affiliation with any clinics. Describe your role and the nature of your affiliation.
- If you are a private practitioner, make sure to provide your practice details.
- Once all fields are completed, save your changes, and choose to download, print, or share the form.
Complete your DHS 1139A online today and ensure a smooth credentialing process.
Get form
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
The name 'Hoku' means 'star' in Hawaiian, highlighting its significance in navigation and spiritual guidance. Stars, including hoku, play an essential role in Hawaiian storytelling and traditions. Understanding the meaning of such terms can enhance your experience as you navigate systems like those outlined in DHS 1139A Instructions.
Get This Form Now!
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.