Skip Ribbon Commands
Skip to main content
Navigate Up
Sign In

Home : forms

download forms graphic

The following documents are stored in pdf icon.pdf format. If you do not have the free Adobe Reader installed, please click the image below before proceeding.
get adobe reader

  dotALLIED HEALTH FORMS
  dotPHYSICIAN LICENSURE FORMS
  dotOTHER FORMS
 

 

 

 

Flag icon Important Information for Veterans, Service Members, and Military Spouses for Expedited Licensing
 
ALLIED HEALTH FORMS
 
Athletic Trainers
pdf iconAthletic Trainers Licensure Application
pdf iconAthletic Trainers Reinstatement Application
pdf iconAthletic Trainers Evaluation and Treatment Protocol
pdf iconAthletic Trainers Evaluation and Treatment Protocol Termination Form
pdf iconAthletic Trainers Alternate Supervising Physician Designation Form
 
Physician Assistants

 

pdf iconPhysician Assistant Licensure Application
pdf iconPhysician Assistant Reinstatement Application
pdf iconPhysician Assistant Delegation Agreement for Core Duties
pdf iconPhysician Assistant Delegation Agreement Addendum for Advanced Duties
pdf iconPhysician Assistant Alternate Supervising Physician Designation Form
pdf iconPhysician Assistant Delegation Agreement Termination Form
pdf iconAdding Prescriptive Authority
 
Polysomnographic Technologists
pdf iconPolysomnographic Technologist Licensure Application
pdf iconPolysomnographic Technologist Reinstatement Application
 
Radiation Therapists, Radiographers, Nuclear Medicine Technologists and Radiologist Assistants
pdf iconRadiation Therapist Licensure Application
pdf iconRadiographer Licensure Application
pdf iconNuclear Medicine Technologist Licensure Application
pdf iconRadiation Therapist, Radiographer, and Nuclear Medicine Technologist Reinstatement Application
pdf iconRadiologist Assistant Licensure Application
pdf iconRadiologist Assistant Advanced Procedures Request Application
pdf icon Diagnostic CT/Nuclear Medicine Device with or without IV Contrast Application
 
Respiratory Care Practitioners
pdf icon Respiratory Care Practitioner Reinstatement Application
 
Other Allied Health Applications
pdf iconAllied Health Change of Address Form
pdf iconAllied Health Name Change Request Form
pdf iconAllied Health Replacement License Request Form
 
PHYSICIAN LICENSURE FORMS
pdf iconApplication for Initial Medical Licensure
pdf iconChange of Address Form
pdf iconPhysician Reinstatement Application
pdf iconApplication for Replacement License/Wall Certificate
pdf iconPhysician Name Change Request Form
pdf iconPhysician Inactive License Status Change Application
pdf iconPhysician Acupuncture Registration Application
pdf iconException from Physician License Application
pdf iconRegistration and Re-registration of Unlicensed Medical Practitioners (UMPS)
pdf iconApplication for Medical License by Conceded Eminence
pdf iconApplication for Exemption from License fee
pdf iconPermit to Dispense Prescription Drugs *Revised for new law effective July 1, 2013

 

** Please note that CEs obtained from the Accreditation Council for Pharmacy Education are acceptable.

pdf iconLimited License for Postgraduate Teaching
 
 
OTHER FORMS
Request for Verification of Licensure/Jurisdiction Clearance Form
Unlicensed Medical Practitioners (UMPs) Information
Complaint Form
pdf iconVideo Order Form
Report of Disciplinary Action Form
pdf iconData/Roster Order Form