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Acupuncture Clinical Practice AffidavitAcupuncture-Clinical-Practice-Affidavit.pdf
  
3/10/2014 3:19 PMNo presence informationCarol Brandt
AC
Clinical Practice Affidavit
My Application
Agent Acknowledgmentall-agent-acknowledgment.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
PA
Practice Agreement,
Practice Description,
PRAG,
PD
My Practice or Personal Information
Authorization to Use and Disclose Informationall-ors192-authorization.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO, DPM, PA, LAc
Authorization, PHI, Record, Disclose, Disclosure
My Practice or Personal Information
Certificate of License Registration - Request for Duplicate all-duplicate-certificate.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA,
LAc
Cert,
Certificate,
License,
Registration,
Duplicate
My Practice or Personal Information
Chronology of Activitiesall-chronology-of-activities.pdf
  
3/10/2014 3:19 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
Chronology,
Activities,
History,
Resume,
Employment
My Application
Closed Malpractice Claims (Monthly)request-closed-malpractice-claims.pdf
  
10/22/2013 11:51 AMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA,
LAc
Malpractice,
Malpractice Claims
Public Information
Complaint Formcomplaint-form.pdf
  
3/27/2014 2:13 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
Complaint,
Care,
Negligence,
Negligent,
Malpractice
Reporting a Licensee
Credit Card Paymentcredit-card-payment.pdf
  
4/9/2014 12:09 PMNo presence informationCarol Brandt
MD/DO, DPM, PA, LAc
Payment, Fees, Credit Card
My Application, My Practice or Personal Information, Public Information
Customer Surveyall-general-survey.pdf
  
9/12/2013 9:51 AMNo presence informationPaxton, Eric
MD/DO, DPM, PA, LAc
Customer Service,
Feedback,
Survey
My Application,
My Practice or Personal Information,
Public Information,
Reporting a Licensee
Dispensing Physician Applicationmddo-dispensing-physician-application.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM
Dispense,
Dispensing,
Registration
My Practice or Personal Information
ECFMG Certification, Request for Status Reportmddo-ecfmg-certification.pdf
  
9/12/2013 9:51 AMNo presence informationPaxton, Eric
MD/DO,
DPM
ECFMG,
Certification,
Education,
Verification,
International,
Foreign
My Application
Federation Disciplinary Inquiryall-disciplinary-inquiries.pdf
  
3/10/2014 3:20 PMNo presence informationCarol Brandt
MD/DO, DPM, PA
FSMB, FPMB, Federation, Disciplinary
My Application
Fingerprint Identification Verificationall-fingerprint ID.pdf
  
9/12/2013 9:52 AMNo presence informationPaxton, Eric
MD/DO,
DPM,
PA,
LAc
Fingerprint,
Verification,
ID Form,
Background Check
My Application,
My Practice or Personal Information
Liability Cap for Donated Servicesall-liability-limitation.pdf
  
3/11/2014 8:13 AMNo presence informationCarol Brandt
MD/DO,
DPM,
PA
Liability,
Liability Cap,
Limitation,
Insurance
My Practice or Personal Information
Liability Cap for Donated Services (Spanish)all-liability-limitation-spanish.pdf
  
3/11/2014 8:14 AMNo presence informationCarol Brandt
MD/DO,
DPM,
PA
Liability,
Liability Cap,
Limitation,
Insurance
My Practice or Personal Information
Licensee Datarequest-data.pdf
  
4/9/2014 11:09 AMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
"Data
Address
List
Info,
Information,
Request,
Aggregate,
Electronic,
CD
Public Information,
My Practice or Personal Information
Licensee File Requestrequest-licensee-file.pdf
  
4/9/2014 12:01 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
Request,
File,
File Copy,
Licensing File,
Info,
Information,
Documents
My Practice or Personal Information,
Public Information"
Licensee Information Requestrequest-licensee-info-verification.pdf
  
4/28/2014 3:38 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
Licensee Info,
Licensee Information,
Verify,
Verification,
Good Standing,
Board Order,
Malpractice
Public Information,
My Practice or Personal Information
Locum Tenens Practice Notificationall-locum-tenens-form.pdf
  
3/27/2014 4:40 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA
Locum,
LT,
Assignment,
Temporary,
Location
My Practice or Personal Information
Malpractice / Medical professional claims explanationmddo-malpractice-claim-explanation.pdf
  
3/21/2014 4:19 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA
Malpractice,
Claim,
Explanation,
History,
Reporting
My Application
Malpractice Claim Reportmalpractice-claim-report-form.pdf
  
1/27/2014 2:17 PMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA
Malpractice,
Claim,
Reporting
My Practice or Personal Information,
Public Information
Material Risk Noticematerial-risk-notice.pdf
  
5/15/2014 10:40 AMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA,
LAc
PARQ,
MRN,
Risk,
Intractable,
Pain,
Pain Management
My Practice or Personal Information
Name Change Affidavitall-affidavit-name-change.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA,
LAc
Name,
Change,
Affidavit,
Marriage,
Divorce,
Naturalization
My Application,
My Practice or Personal Information
Naturalization Affidavitall-affidavit-naturalization.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM,
PA,
LAc
Name,
Naturalization,
Identity,
Foreign,
Citizenship,
Legal
My Application
NCCPA Certification Verification and Exam Historypa-nccpa-certification.pdf
  
9/12/2013 9:56 AMNo presence informationPaxton, Eric
PA
Certification, Exam History
My Application
Personal History Questions, Explanation of Affirmative Responsesall-personal-history-explanations.pdf
  
3/10/2014 3:31 PMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
PHQ,
Affirmative,
Affirmative Answers,
Yes Answers,
Response
My Application
Practice Agreement Sample -- REFERENCE ONLYall-practice-agreement-watermark.pdf
  
9/12/2013 9:56 AMNo presence informationPaxton, Eric
MD/DO,
PA
Practice Agreement,
Practice Description,
PRAG,
PD
My Application,
My Practice or Personal Information
Practice Agreement/Description Copy Requestall-request-practice-agreement-description.pdf
  
4/9/2014 12:02 PMNo presence informationCarol Brandt
MD/DO,
PA
Practice Agreement,
Practice Description,
PRAG,
PD
My Practice or Personal Information,
Public Information
Practice of Medicine Across State Lines (Telemedicine) Practice Descriptionmddo-telemedicine-request.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM
Telehealth,
Telemed,
Telemedicine,
Practice,
Practice Plans,
State
My Application
Records Request Formrequest-public-records.pdf
  
4/16/2014 10:17 AMNo presence informationCarol Brandt
MD/DO,
DPM,
PA,
LAc
Request,
Info,
Information,
Record,
Public
Public Information
Verification - Educationacpa-verification-education.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
PA,
LAc
Physician Assistant,
PA,
Acupuncturist,
LAc,
Verify,
Verification,
Education
My Application
Verification - Health Related Employmentacpa-health-related-employment-verification.pdf
  
10/10/2013 4:35 PMNo presence informationRandall Wagenmann
PA,
LAc
Physician Assistant,
PA,
Acupuncturist,
LAc,
Verify,
Verification,
Education
My Application
Verification - Health Related Licenseacpa-health-related-license-verification.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
PA,
LAc
Verify,
Verification,
License,
Health
My Application
Verification - Internship, Residency, Fellowship Trainingmddo-verification-internship-training.pdf
  
9/12/2013 9:57 AMNo presence informationPaxton, Eric
MD/DO,
DPM
Verify,
Verification,
Internship,
Residency,
Fellowship,
Training,
Postgraduate,
PG,
Med Ed
My Application
Verification - Licensure and Certification of State Board Written Examination Gradesmddo-verification-licensure.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM
Verify,
Verification,
USMLE,
National Board,
Transcripts,
FLEX,
LLMC,
Reciprocity,
Exam,
License
My Application
Verification - Medical Educationmddo-verification-medical-education.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO, DPM
Verify, Verification, Education, School, Med School, Med Ed, Medical School
My Application
Verification - Podiatric Hospital Privileges to Perform Ankle Surgerymddo-verification-podiatric-privileges.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
DPM
Verify,
Verification,
Podiatric,
Ankle,
Surgery,
Privileges
My Application
Verification - Practice, Employment, Staff membershipmddo-verification-employment.pdf
  
10/10/2013 4:36 PMNo presence informationRandall Wagenmann
MD/DO,
DPM
Verify,
Verification,
Employment,
Staff,
Privileges
My Application