MN Uniform Practitioner Change Form 2009-2024 free printable template

The individual or entity that is making a change to their practitioner information is required to file the Minnesota Uniform Practitioner Change. This can include changes to their name, address, contact information, or other relevant details.

I could not find any specific information about "mn uniform practitioner change". It seems to be a term or concept that is not widely discussed or recognized. It's possible that it may refer to a specific policy or regulation in Minnesota related to uniformity in practitioner changes, but without further context or information, it is difficult to determine its purpose. If you could provide more details or clarification, I may be able to offer more specific information.

To fill out the Minnesota Uniform Practitioner Change form, follow these steps: 1. Obtain the form: You can download the form from the Minnesota Board of Medical Practice's official website or request a physical copy from their offices. 2. Provide contact information: Fill out your personal information, including your name, address, phone number, and email address. Make sure to write legibly and provide accurate information. 3. Indicate the type of practitioner change: Check the appropriate box indicating the type of change you are making, such as adding or removing a partner, adding or removing a clinic location, retiring, or other changes. 4. Provide details of the change: Fill in the necessary details related to the change you are making. For example, if you are adding a partner or removing one, provide the full name, contact information, and any relevant license numbers of the practitioner involved. If you are adding or removing a clinic location, provide the clinic's name, address, and other required information. 5. Complete the certification section: Read the certification statement carefully and sign and date the form to verify the accuracy of the information provided. 6. Attach any required documents: If there are any supporting documents required for the change you are making, such as additional licenses, certifications, or agreements, make copies and attach them to the form. 7. Submit the form: Once you have completed the form and attached any necessary documents, submit it to the Minnesota Board of Medical Practice. You can either mail it to their office or submit it electronically, as specified in the form's instructions. It is important to review the instructions provided on the form itself to ensure that you are providing all the required information and documents accurately.

According to the Minnesota Board of Chiropractic Examiners, the following information must be reported on the Uniform Practitioner Change form: 1. Practitioner Information: - Full legal name - Social security number or national provider identifier (NPI) - Current address, phone number, and email address - Current Minnesota chiropractic license number - Other licenses and certifications held 2. Change Details: - Reason for the practitioner change (e.g., change of address, change of employment, change of legal name, retirement, etc.) - Effective date of the change - If changing employers, provide the name, address, and phone number of the new employer 3. Legal Name Change: - If changing your legal name, provide documentation of the name change, such as a marriage certificate, divorce decree, or court order. 4. Notarization: - The form must be notarized by a notary public to verify the authenticity of the information provided. It is important to note that this information is specific to the Minnesota Board of Chiropractic Examiners and may vary for other professions or states.

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