Proview errors copy
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The document contains a form requesting information about a practitioner's professional licenses, certifications, and practice status. It notes several required fields need to be completed, including details about a license for the state of Virginia and expiration dates.
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Proview errors copy
- 1. License Number License Type Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certi鍖cate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certi鍖cate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certi鍖cate Yes No License State ADD 6829475 State* Do you currently practice in this in this state? Yes No
- 2. License State Do you currently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certi鍖cate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certi鍖cate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certi鍖cate Yes No ADD
- 3. License State Do you currently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certi鍖cate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certi鍖cate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certi鍖cate Yes No ADD Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "State"
- 4. License State Do you currently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certi鍖cate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certi鍖cate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certi鍖cate Yes No ADD Please enter the 鍖eld labeled, "License State" Please enter the 鍖eld labeled, "Do you currently practice in this state?" Please enter the 鍖eld labeled, "License Number" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "Expiration Date" Please enter the 鍖eld labeled, "State" Please enter the 鍖eld labeled, "State" Select Date Select Date Please Select Please Select