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ALLIED HEALTH FORMS

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PHYSICIAN LICENSURE FORMS

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OTHER FORMS

 

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ALLIED HEALTH FORMS
 
Athletic Trainers
pdf icon Licensure Application
pdf icon Reinstatement Application
pdf icon Alternate Supervising Physician Designation Form
pdf icon Evaluation and Treatment Protocol
pdf icon Evaluation and Treatment Protocol Termination Form
 
Perfusionists
pdf icon Licensure Application
 
Physician Assistants
pdf icon Licensure Application
pdf icon Reinstatement Application
pdf icon Adding Prescriptive Authority
pdf icon Alternate Supervising Physician Designation Form
pdf icon Delegation Agreement Addendum for Advanced Duties
pdf icon Delegation Agreement for Core Duties
pdf icon Delegation Agreement Termination Form
 
Polysomnographic Technologists
pdf icon Licensure Application
pdf icon Reinstatement Application
 
Radiation Therapists, Radiographers, Nuclear Medicine Technologists and Radiologist Assistants
pdf icon Nuclear Medicine Technologist Licensure Application
pdf icon Radiation Therapist Licensure Application
pdf icon Radiation Therapist, Radiographer, and Nuclear Medicine Technologist Reinstatement Application
pdf icon Radiographer Licensure Application
pdf icon Radiologist Assistant Advanced Procedures Request Application
pdf icon Radiologist Assistant Licensure Application
pdf icon Diagnostic CT/Nuclear Medicine Device with or without IV Contrast Application
pdf icon Non-Diagnostic CT/Nuclear Medicine Device without IV Contrast Application
 
Respiratory Care Practitioners
pdf icon Licensure Application
pdf icon Reinstatement Application
 
Other Allied Health Applications
pdf icon Allied Health Change of Address Form
pdf icon Allied Health Name Change Request Form
pdf icon Allied Health Replacement License Request Form
 
Physician Licensure Forms
pdf icon Initial Medical Licensure
pdf icon Reinstatement Application
pdf icon Exemption from License fee
pdf icon Medical License by Conceded Eminence
pdf icon Replacement License/Wall Certificate
pdf icon Change of Address Form
pdf icon Exception from Physician License Application
pdf icon Limited License for Postgraduate Teaching

pdf icon Application Form - Permit 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 icon Acupuncture Registration Application
pdf icon Inactive License Status Change Application
pdf icon Physician Name Change Request Form
pdf icon Registration and Re-registration of Unlicensed Medical Practitioners (UMPS)
 
 
OTHER FORMS
Complaint Form
pdf icon Data/Roster Order Form
Mandated 10-Day Report Form
Request for Verification of Licensure/Jurisdiction Clearance Form
Unlicensed Medical Practitioners (UMPs) Information
pdf icon Video Order Form