Healing the Children Northeast

MTAP Application & Forms

DOWNLOADABLE FORMS

STEP 2

After completion of the online registration Fax or Scan the following credentials to the HTCNE Office: (860-350-6634)

Copies of:

Current Medical License

Medical or Nursing School Diploma

CV / Resume

Delineation of Privileges

STEP 3

Fax the following forms to the HTCNE Office: (860-350-6634)

Click here to download the Member Packet of forms.

Credit Card Authorization Form

Medical History Form

Release from Liability Form

Scan and email your Passport Photo Page to mlaw@htcne.org.

DO NOT FAX YOUR PASSPORT
(we'll only ask you to send it)

Healing the Children Northeast • PO Box 129, 219 Kent Road, New Milford, CT 06776
Telephone (860) 355-1828 • Fax (860) 350-6634