Maine Uniform Application for Initial Appointment Completed Form Examples and Samples
Explore a comprehensive, filled-out example of the Maine Uniform Application for Initial Appointment. Our detailed sample provides a clear guide for physicians and healthcare providers on how to accurately complete each section for successful credentialing and privileging in Maine.
Maine Uniform Application for Initial Appointment Example
How this form was filled:
This example shows a completed Maine Uniform Application for a fictional Family Medicine physician, Dr. Emily Carter, applying for initial appointment. It includes accurately filled sections for personal data, licensure, education, professional liability insurance, and attestation questions, reflecting a standard 'clean' application.
Information used to fill out the document:
- Applicant Name: Emily R. Carter, MD
- Application Type: Initial Appointment
- Specialty: Family Medicine
- National Provider Identifier (NPI): 1234567890
- DEA Number: EC9876543
- Maine Medical License Number: MED12345
- License Issue Date: 07/01/2025
- License Expiration Date: 06/30/2027
- Primary Practice Address: 100 Main Street, Suite 200, Brunswick, ME 04011
- Medical School: Tufts University School of Medicine
- Graduation Date: 05/15/2019
- Residency Program: Maine Medical Center - Family Medicine Residency
- Residency Completion Date: 06/30/2022
- Professional Liability Carrier: Medical Mutual Insurance Company of Maine
- Policy Number: MMICM456789
- Coverage Amount: $1,000,000 / $3,000,000
- Policy Period: 07/01/2025 to 06/30/2026
- Attestation Questions (e.g., felony convictions, license limitations): All answered 'No'
- Signature Date: 03/10/2026
What this filled form sample shows:
- Accurate entry of NPI, DEA, and Maine state medical license numbers.
- Complete education and post-graduate training history with correct dates.
- Properly documented professional liability insurance details.
- Correctly answered attestation questions for a standard applicant, crucial for credentialing.
- Clear formatting of all personal, practice, and professional information.
Form specifications and details:
| Form Name: | Maine Uniform Application for Initial Appointment |
| Use Case: | Physician (MD) applying for initial hospital privileges in Maine. |
| Applicant Profile: | Family Medicine specialist with a clean professional and personal history. |
Created: January 31, 2026 01:42 AM
