Maryland Uniform Credentialing Form

Tennessee Uniform Credentialing Form

Section 3 of 8: Professional / Medical Specialty Information
Primary Specialty:
Do you have a primary specialty to enter?*

YesNo
Please Select Specialty:
Auto field for Specialty Code 1:
Specialty Code 1:
Are you board certified?

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

Please select one if not board certified:

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.
Fax Number:
Please enter a valid phone number.
Email:
example@example.com
Should be Empty:

	Yes	No	Expiration Date: (MM/DD/YYY)
Basic Life Support:
CPR:
Advanced Cardiac Life Support:
Neonatal Advanced Life Support:
Advanced Life Support in OB:
Advanced Trauma Life Support:
Pediatric Advanced Life Support:

Tennessee Uniform Credentialing Form