Maryland Uniform Credentialing Form - Section 3

Tennessee Uniform Credentialing Form

Section 3 of 8: Professional / Medical Specialty Information
Primary Specialty:
YesNo
Please Select Specialty:
Auto field for Specialty Code 1:
Specialty Code 1:
YesNo
Please Select Certifying Board:
Auto field for Specialty Board Code 1:
Specialty Board Code 1:
Initial Certification Date:

MonthDayYear
Date
Recertification Date (If Applicable):

MonthDayYear
Date
Expiration Date (If Applicable):

MonthDayYear
Date

Do you wish to be listed in the directory under this specialty?

Rows	Yes	No
HMO
PPO
POS

I have taken exam, results pending for...I intend to sit for an exam on...I do not intend to take a certifying board exam...
Please Select Certifying Board:
Auto field for Specialty Board Code 2:
Specialty Board Code 2:
Please enter exam date:

MonthDayYear
Date
Please use the space below to explain why you did not intend to take a certifying board exam.

Tennessee Uniform Credentialing Form

Section 3 of 8: Professional / Medical Specialty Information
Practice Interests:

Provide additional areas of professional practice interest, activities, procedures, diagnoses or populations. You do not have to fill out all 10.
Interest 1:
Interest 2:
Interest 3:
Interest 4:
Interest 5:
Interest 6:
Interest 7:
Interest 8:
Interest 9:
Interest 10:

Tennessee Uniform Credentialing Form

Section 3 of 8: Professional / Medical Specialty Information
Primary Credentialing Contact:
Full Name:

First NameMiddle InitialLast Name
Address:
Street Number:
Street Name:
Suite/Building Number:
City:
State:
Zip Code:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Should be Empty: