Form 0917-0009 Education Verification
Indian Health Service Medical Staff Credentials Application
Form_Education Verification FINAL 04.13.23
Education Verification
OMB: 0917-0009
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service
Indian Health Service
«FacilityName»
FacilityAddress
EDUCATION VERIFICATION
«RS_Name»
«RS_Address» «RS_Address2»
«RS_City», «RS_State» «RS_Zip»
PHONE: |
«RS_Telephone» |
FAX: |
«RS_Fax» |
RE: |
«FormalNameWithDegree» |
DOB: SSN: |
«BirthDate» «SSN» |
Dear Sir/Madam:
The practitioner listed above has applied for appointment to our facility.
Before we can process this application further, we require verification or completion of the following information regarding the applicant's training at your institution:
Type of Degree/Residency/Fellowship/Internship:
Inclusive Date of Attendance: To
Completed in good standing: Yes No
Was the practitioner ever subject to disciplinary proceedings or action at your facility? Yes* ___ No _____
Verified by:
Title: Date:
*If applicable, on a separate sheet of paper, please indicate any sanctions or disciplinary actions taken against
the practitioner during training, as well as any other pertinent information that would assist us in considering the applicant's appointment to our facility. A signed release is attached. «Image:File_REL»
Respectfully,
«UserFullName»
Medical Staff Professional
Medical Staff Office
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | {#FILE "GRADDR |
| Author | CBR Associates, Inc. |
| File Modified | 0000-00-00 |
| File Created | 2023-08-02 |
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