Form PH-4183 Attachment 2 "Verification of Postgraduate Medical Training" - Tennessee

What Is Form PH-4183 Attachment 2?

This is a legal form that was released by the Tennessee Department of Health - a government authority operating within Tennessee.The document is a supplement to Form PH-4183, Declaration of Citizenship. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the Tennessee Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PH-4183 Attachment 2 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Health.

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Download Form PH-4183 Attachment 2 "Verification of Postgraduate Medical Training" - Tennessee

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ATTACHMENT 2
TENNESSEE BOARD OF MEDICAL EXAMINERS
(800) 778-4123, ext. 532-4384 or (615) 532-3202, ext. 532-4384
VERIFICATION OF POSTGRADUATE MEDICAL TRAINING
APPLICANT: Provide the information requested in the top box and then mail this form to each institution in which
you received any postgraduate medical training. If additional forms are required, copy this one.
Institution Administration: I am applying for a Tennessee medical license and hereby authorize you to release any and all
information in your files concerning my medical training. I was in training at your institution as follows:
Applicant's name:
(Last)
(First)
(Middle/Maiden)
Name of Institution:
Program Title:
Applicant's Signature
Dates
THIS PORTION IS TO BE COMPLETED BY THE TRAINING PROGRAM’S ADMINISTRATIVE OFFICE
Please complete (including questions) and return to:
State of Tennessee
Board of Medical Examiners
665 Mainstream Drive
Nashville, TN 37243
CIRCLE ONE
Is your training program currently ACGME approved?
Yes
No
Was the above program LCME/ACGME approved at the time the applicant completed training?
Yes
No
Were there any adverse charges or actions taken during the residency?
Yes
No
If yes, please attach supporting information and/or documentation.
Would you recommend the applicant for licensure?
Yes
No
Did the applicant successfully complete the program?
Yes
No
The applicant attended the program from
to
. I certify that the information on this form is true and
correct.
(Mo/Yr)
(Mo/Yr)
Program Director's/Dean's Signature
Date
Subscribed and sworn before me this the
day of
,
.
Notary Public
(Affix Seal Here)
My Commission Expires:
PH-4183(Rev.02/17)
RDA 10137
ATTACHMENT 2
TENNESSEE BOARD OF MEDICAL EXAMINERS
(800) 778-4123, ext. 532-4384 or (615) 532-3202, ext. 532-4384
VERIFICATION OF POSTGRADUATE MEDICAL TRAINING
APPLICANT: Provide the information requested in the top box and then mail this form to each institution in which
you received any postgraduate medical training. If additional forms are required, copy this one.
Institution Administration: I am applying for a Tennessee medical license and hereby authorize you to release any and all
information in your files concerning my medical training. I was in training at your institution as follows:
Applicant's name:
(Last)
(First)
(Middle/Maiden)
Name of Institution:
Program Title:
Applicant's Signature
Dates
THIS PORTION IS TO BE COMPLETED BY THE TRAINING PROGRAM’S ADMINISTRATIVE OFFICE
Please complete (including questions) and return to:
State of Tennessee
Board of Medical Examiners
665 Mainstream Drive
Nashville, TN 37243
CIRCLE ONE
Is your training program currently ACGME approved?
Yes
No
Was the above program LCME/ACGME approved at the time the applicant completed training?
Yes
No
Were there any adverse charges or actions taken during the residency?
Yes
No
If yes, please attach supporting information and/or documentation.
Would you recommend the applicant for licensure?
Yes
No
Did the applicant successfully complete the program?
Yes
No
The applicant attended the program from
to
. I certify that the information on this form is true and
correct.
(Mo/Yr)
(Mo/Yr)
Program Director's/Dean's Signature
Date
Subscribed and sworn before me this the
day of
,
.
Notary Public
(Affix Seal Here)
My Commission Expires:
PH-4183(Rev.02/17)
RDA 10137