Get georgia uniform healthcare practitioner credentialing application form 2006-2024

Ntialing Application Form Page ii GEORGIA UNIFORM HEALTHCARE PRACTITIONER CREDENTIALING APPLICATION FORM ***************PART ONE*************** If more space than is provided on this Application is needed in order to answer a question completely, please use the attached Explanation Form as necessary. I. IDENTIFYING INFORMATION Please provide the practitioner’s full legal name. Last Name (include suffix; Jr., Sr., III): First: Middle: Degree(s): Is there any other name under which you.

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