If you are unable to complete the form online, you may download as a pdf,
complete and email a scanned copy to gilliam@heartsinmotion.org or fax to (219) 922-1694.

Health Care Provider Information Form

Name
Specialty
 
Board Certified?
 
Board Eligible?
 
Board Certification Date?
  States in which you hold valid registration or licenses:

State
License
Exp.Date
State
License
Exp.Date
State
License
Exp.Date
 
Have you ever had a professional license revoked or suspended:?
 
Has your employment or clinical privileges ever been voluntarily, or involuntarily suspended, diminished, revoked, limited or not renewed at any health care facility:?
 
If you answered yes to either question, please explain:
Professional References:

Name
Title
Institution
Phone
Name
Title
Institution
Phone
 
I certify that to the best of my knowledge and belief the above information is true and complete and that the accompanying document(s) are valid.
 
Date of digital signature?
After submitting this form you will be returned given the opportunity to UPLOAD the required documents or you may Fax or Email them to HIM Headquarters.




HEADQUARTERS

Phone: 219-924-2446
Fax: 219-922-1694
2210 US 41
Schererville, Indiana 46375
Click here to email

Guatemala Office

Barrio La Barca
Gualan, Zacapa
Guatemala, Central America

Kentucky Office

2601 Evergreen Wynde
Louisville, KY. 40223
Phone 502-523-2695
himlouisville@hotmail.com

Oklahoma Office

1203 East 30th Place
Tulsa, OK. 74114
Phone 281-684-9741
marciamcginnis@comcast.net

Wisconsin Office

S67 W32615 Ashton Way E
Mukwonago, WI. 53149
Phone 262-490-7009
heartsinmotionwis@yahoo.com


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