Form 40-2-3-E Provider Clinical Assessment And Qualification

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PROVIDER CLINICAL ASSESSMENT AND QUALIFICATION

Page 1 of 3

(For use of this form, see USMEPCOM Reg 40-2)

PRIVACY ACT STATEMENT

Authority: Title 5, United States Code (USC), Sections 301 and 552a; Title 44, USC, Section 3101; Title 10, USC, Section 1071.

Principal Purpose: To document the provider's professional qualifications as the basis for medical services appointment.

Routine Uses: To support the Provider Quality Management Program (PQMP). A copy of this form will be retained in the provider's PQMP file. Information may be provided to certain civilian

institutions, the Federation of State Medical Boards of the U.S., State Licensure Authorities, and other appropriate professional regulatory bodies.

Disclosure: Disclosure of information requested is voluntary. However, failure to provide the required information may interfere with the timely granting of your medical services appointment.

SECTION A - PROVIDER'S INFORMATION

1. Full Name:

2. National Provider Identifier (NPI):

3. Current DPC Level:

(Last, First, Middle)

5. Assessment Period

4. Function:

(MMM DD, YYYY)

CMO

Asst CMO (ACMO)

From:

To: