Medical Scribe Declaration Form
Please complete this form to declare your role and responsibilities as a medical scribe.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employer / Facility Name
*
Supervisor / Physician Name
*
Role or Position
*
Please Select
Medical Scribe
Lead Scribe
Scribe Trainer
Other
Attestation
*
Signature
*
Submit Declaration
Submit Declaration
Should be Empty: