**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**
1
Do you possess a current certificate as a Nurse Practitioner or as a Nurse Midwife from the Maryland State Board of Nursing or compact state?
Yes
No
2.
Please provide your license number and expiration date in the box below.
3
Describe in 1-3 paragraphs, your experience in WIC or Maternal/Child Health.
Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
4
Describe in 1-3 paragraphs, your experience in using an EMR (Electronic Medical Record).
Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
5
Describe in 1-3 paragraphs, your experience in using online clinical knowledge databases (example- UpToDate) or researching clinical questions during patient visits.
Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
6
Describe in 1-3 paragraphs, your experience in ICD-10 billing procedures (diagnosis codes, procedure codes, modifiers).
Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
7
Describe in 1-3 paragraphs, your experience working with uninsured and underinsured patients.
Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
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