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 has a very complex Form Complexity Index of 87/100 — Instafill’s AI completes it in under a minute.
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Completed Maine Uniform Application for Initial Appointment for a family medicine physician.

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
Completed Maine Uniform Application for Initial Appointment for a family medicine physician.