Forms
Note: Fill-in forms provide the ability to type in the fields; however, all forms must be printed, signed, and mailed.
Consumer:
- Consumer Complaint Form - Fill-In
- Consumer Complaint Form (Spanish Version) - Fill-In
- Consumer Response Form - Fill-In
- Request for Certified Public Documents Form
License Verification (LVS):
- Licensing Verification System Subscription Service Form - Fill-In
- Licensing Verification System Subscription Renewal Form - Fill-In
- Request for Copy of 805 Report - Fill-In
- Security Agreement Form - Accessing the Licensing Verification System - Fill-In
- Subscription Service Request - Credentialing Services - Fill-In
Licensees:
- Application for Cancellation of a Fictitious Name Permit - Fill-In
- Application for Continuing Medical Education (CME) Waiver - Fill-In
- Application for Duplicate Certificate - Fill-In
- Application for Duplicate Fictitious Name Permit - Fill-In
- Application for Inactive License - Fill-In
- Application for Voluntary Surrender of License
- Application to Restore License to Full, Active Status from Inactive, Disabled or Fee Exempt Status or from Disabled Status to Active Status with Limitations on Practice
- Armed Forces Personnel Application for Exemption from Payment of Renewal Fee - Fill-In
- Armed Forces Combat Readiness Training Registration Form - Fill-In
- Change of Address - Fill-In
- Declaration of Custodian of Records - Fill-In
- Disabled Physician Application for Exemption from Payment of Renewal Fee - Fill-In
- Fictitious Name Permit Application - Fill-In
- Fictitious Name Permit Change of Address Form - Fill-In
- Fictitious Name Permit Notification of Partnership Change - Fill-In
- Fictitious Name Permit Notification of Shareholder Change - Fill-In
- Fictitious Name Permit Notification of Renewal/Hold Release - Fill-In
- Notification of Name Change
- Petition for Penalty Relief
- Physician Orders for Life Sustaining Treatment (POLST) form
- Retired Physician Application for Exemption from Payment of Renewal Fee - No Practice Allowed - Fill-In
- Voluntary Service Physician Application for Waiver from Payment of Initial License or Renewal Fee - Fill-In
Applicants:
- Application for Licensure
- Application for Licensed Midwife
- Application for Registration as a Contact Lens Dispenser
- Application for Registration as a Dispensing Optician - Fill-In
- Application for Registration as a Nonresident Contact Lens Dispenser - Fill-In
- Application for Registration as a Spectacle Lens Dispenser
- Application for Registration as a Student Research Psychoanalyst - Fill-In
- Application for Research Psychoanalyst Registration - Fill-In
- Fingerprint, Live Scan (Physician and Surgeon applicants only)
- Fingerprint, Live Scan (Lens Dispenser applicants only)
- Fingerprint, Live Scan (Midwife applicants only)
Mandatory Reporting:
- Health Facility/Peer Review Reporting Form (805 Report) - Fill-In
- 805 Fact Sheet
- Health Facility Reporting Form - Proposed Action (805.01 Report) - Fill-In
- Outpatient Surgery - Patient Death Reporting Form - Fill-In
- Patient Transfer Reporting Form - Fill-In
- Physician Reporting - Criminal Actions (802 Report) - Fill-In
- Report of Settlement, Judgment, or Arbitration Award (801 Report) - Fill-In
- Reporting Requirements for Coroners
- Reporting Requirements for Court Clerks
Allied Health:
- Application for Registration as a Contact Lens Dispenser
- Application for Registration as a Dispensing Optician - Fill-In
- Application for Registration as a Nonresident Contact Lens Dispenser - Fill-In
- Application for Registration as a Spectacle Lens Dispenser
- Application for Registration as a Student Research Psychoanalyst - Fill-In
- Application for Research Psychoanalyst Registration
- Sample Licensed Midwife Disclosure Form
- Registered Dispensing Optician Cancellation of Certificate - Fill-In
