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The individual listed here must sign the provider agreement. Last Name First Middle Medical License Number Medicaid or NPI Number Title MD DO NP PA Specialty Employer Identification Number optional Provide information for second individual as needed VFC VACCINE COORDINATOR Primary Vaccine Coordinator Last Name Completed annual training Yes Back-Up Vaccine Coordinator Last Name DOH-3836 5/14 page 1 of 6 No Type of training received ADDITIONAL PROV...

How to fill out doh form pdf

How to fill out the DOH 3836 form:

1. Begin by downloading the DOH 3836 form from the appropriate website or obtain a physical copy from the relevant healthcare facility.
2. Fill in the personal information section, including your name, address, date of birth, and contact details.
3. Provide the required details of your healthcare provider, such as their name, address, and contact information.
4. Specify the type of healthcare service provided, whether it is outpatient, inpatient, or emergency care.
5. Indicate the dates of service, including the start and end dates, to accurately document the duration of your healthcare service.
6. Include any relevant payment information, such as insurance details or self-pay information.
7. Sign and date the form to certify the accuracy and completeness of the information provided.
8. Review the filled-out form for any errors or omissions before submitting it to the appropriate entity.

Who needs the DOH 3836 form:

1. Patients who have received medical treatment, whether it is outpatient, inpatient, or emergency care, need to complete the DOH 3836 form.
2. Healthcare providers and facilities use this form for record-keeping and to submit necessary information to the relevant authorities.
3. Insurance companies may also require the DOH 3836 form as part of the claims process or to determine reimbursement eligibility.

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What is doh 3836 form?

The DOH 3836 form is a document used by the Department of Health to collect specific information about healthcare facilities.

Who is required to file doh 3836 form?

Healthcare facilities such as hospitals, clinics, nursing homes, and other healthcare providers are required to file the DOH 3836 form.

How to fill out doh 3836 form?

To fill out the DOH 3836 form, the healthcare facility needs to provide the requested information such as facility details, patient statistics, and specific data required by the Department of Health.

What is the purpose of doh 3836 form?

The purpose of the DOH 3836 form is to gather important data and statistics about healthcare facilities, which helps the Department of Health in monitoring and improving the quality of healthcare.

What information must be reported on doh 3836 form?

The DOH 3836 form requires healthcare facilities to report information such as patient admission and discharge statistics, infection rates, staffing levels, and other relevant data as determined by the Department of Health.