Form Emedny-490301 - Application For Enrollment As A Specialist Form - New York State Department Of Health

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Mail to: Computer Sciences Corporation
P.O. Box 4610
Rensselaer, NY 12144-4610
New York State Department of Health
Application for Enrollment as a Specialist
1. Type or print the information requested in the space provided.
2. Submit a copy of one of the following appropriate documents:
a. certification by an appropriate specialty board; or
b. notice of admissibility to final examination from appropriate specialty board; or
evidence of satisfactory completion of residency or fellowship training.
c.
Section A - Applicant Information
1. Name
Last
First
MI
2. Address
City
State
Zip
3. License Number
State
National Provider Identifier (NPI)
Provider #
4. Social Security #
5. Specialty(ies) Requested
Code Numbers (see page 2)
Section B - Education and Training Institutions
Medical/Dental – Name & City, State
Degree/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Internship – Name & City, State
Degree/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Residency – Name & City, State
Degree/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Fellowship – Name & City, State
Degree/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Section C - Hospital Appointment Information (for last five years only)
Name & City, State
Hours/Week
Title/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Name & City, State
Hours/Week
Title/Specialty
From
/
to
/
MM
/
YY
MM
/
YY
Section D - U.S. Specialty Board Certification(s)
Name of Board
Certification Date
/
/
MM
/
DD
/
YY
Name of Board
Certification Date
/
/
MM
/
DD
/
YY
Section E - Orthodontists Only
If not in exclusive practice, what % of practice is devoted to orthodontics?
%
General Practice From
/
/
to
/
/
MM
/
DD
/
YY
MM
/
DD
/
YY
Orthodontics From
/
/
to
/
/
MM
/
DD
/
YY
MM
/
DD
/
YY
Original Signature
Date
EMEDNY-490301 (03/14)
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