Consumers:

• Consumer Complaint Form
• Consumer Complaint Form (Spanish Version)
• Consumer Response Form
• Request for Certified Public Documents Form

Back to Top

License Verification System (LVS):

• License Verification System Subscription Form
• License Verification System Subscription Form - Credentialing Services

Back to Top

Applicants:

• Physicians and Surgeons

  • U.S. or Canadian Medical School Graduate Application
    • Individual Forms [+]
      • License Information for U.S. or Canadian Medical School Graduates
      • Fee Schedule
      • Live Scan Information
      • Application - Forms L1A-L1F
      • Explanation for Application Question
      • Timeline of Activities Form
      • Certificate of Medical Education - Form L2
      • Certificate of Completion of ACGME/RCPSC Postgraduate Training - Forms L3A-L3B
      • Current Postgraduate Training Enrollment - Form L4
  • International Medical School Graduate Application
    • Individual Forms [+]
      • License Information for International Medical School Graduates
      • Fee Schedule
      • Live Scan Information
      • Translation of International Academic Credentials
      • Application - Forms L1A-L1F
      • Explanation for Application Question
      • Timeline of Activities
      • Certificate of Medical Education - Form L2
      • Certificate of Completion of ACGME/RCPSC Postgraduate Training - Forms L3A-L3B
      • Current Postgraduate Training Enrollment - Form L4
      • Certificate of Clinical Training - Form L5
      • Certificate of Individual Clinical Clerkship Training - Form L6, if applicable
  • Postgraduate Training Authorization Letter (PTAL) Application
    • Individual Forms [+]
      • Application Information for a Postgraduate Training Authorization Letter (PTAL)
      • Fee Schedule
      • Live Scan Information
      • Translation of International Academic Credentials
      • Application - Forms L1A-L1F
      • Explanation for Application Question
      • Timeline of Activities
      • Certificate of Medical Education - Form L2
      • Certificate of Completion of ACGME/RCPSC Postgraduate Training - Forms L3A-L3B
      • Certificate of Clinical Training - Form L5
      • Certificate of Individual Clinical Clerkship Training - Form L6, if applicable
  • Previously Licensed California Physician Application
    • Individual Forms [+]
      • Application Information for a Previously Licensed California Physician
      • Fee Schedule
      • Live Scan Information
      • Application - Forms L1A-L1F
      • Explanation for Application Question
      • Certificate of Completion of ACGME/RCPSC Postgraduate Training - Forms L3A-L3B
  • Limited Practice License Application
    (Applicant must also printout either the US/Canadian Medical School Graduate Application or the International Medical School Graduate Application)
    • Individual Forms [+]
      • Application Information for a Limited Practice License
      • Application - Form LPL
  • Addendums and Other Forms
    • Fingerprint, Live Scan (Physician and Surgeon applicants only)
    • Applicant Declaration, Signature & Notary, Form L1F (Required for Applications submitted using the BreEZe online application system)
    • Explanation for Application Question
    • Addendum to Question #16
    • Addendum to Question #24
    • Applicant Address Change Request
    • Postgraduate Training Registration Form
    • Fictitious Name Permit Application
  • Official Use Only (Medical School Officials, Program Directors, and Hospitals)
    • Certificate of Medical Education, Form L2 (Medical School use only)
    • Certificate of Completion of ACGME/RCPSC Postgraduate Training, Form L3A-L3B (Program Director's use only)
    • Current Postgraduate Training Enrollment, Form L4 (Program Director's use only)
    • Certificate of Clinical Training, Form L5 (Medical School use only)
    • Certificate of Individual Clinical Clerkship Training, Form L6 (Hospital use only)

• Midwives

  • Application for Midwifery License
  • Fingerprint, Live Scan (Midwife applicants only)

• Polysomnography

  • Polysomnography Registration Application
  • Fingerprint, Live Scan (Polysomnography applicants only)

• Research / Student Research Psychoanalysts

  • Application for Research/Student Research Psychoanalyst
  • Fingerprint, Live Scan (Research/Student Research Psychoanalyst applicants only)

Back to Top

Licensees:

• Notice of Change of Address/Email
• Notification of Name Change

• Physicians and Surgeons

  • Application for Cancellation of a Fictitious Name Permit
  • Application for Waiver of Continuing Medical Education During Renewal Cycle
  • Application for Duplicate Certificate
  • Application for Duplicate Fictitious Name Permit
  • Application for Inactive License
  • 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
  • Disabled Physician Application for Exemption from Payment of Renewal Fee
  • Fictitious Name Permit Application
  • Fictitious Name Permit Change of Address Form
  • Fictitious Name Permit Notification of Partnership Change
  • Fictitious Name Permit Notification of Shareholder Change
  • Fictitious Name Permit Notification of Renewal/Hold Release
  • 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
  • Voluntary Service Physician Application for Waiver from Payment of Initial License or Renewal Fee

• Midwives

  • Licensed Midwife Disclosure Form
  • Midwife Application for Inactive License
  • Midwife Application to Restore License to Full, Active Status from Inactive or Retired Status
  • Retired Midwife Application for Exemption from Payment of Renewal Fee - No Practice Allowed
  • Transfer of Planned Out-of-Hospital Delivery to Hospital Reporting Form

Back to Top

Mandatory Reporting:

• Adverse Event Reporting Form for Accredited Outpatient Surgery Settings
• Health Facility/Peer Review Reporting Form (805 Report)
• Health Facility Reporting Form - Proposed Action (805.01 Report)
• Outpatient Surgery - Patient Death Reporting Form
• Patient Transfer Reporting Form
• Physician Reporting - Criminal Actions (802 Report)
• Report of Settlement, Judgment, or Arbitration Award (801 Report)
• Reporting Requirements for Coroners
• Reporting Requirements for Court Clerks

Back to Top

Expert Reviewer:

• Expert Reviewer Program – Original Application
• Expert Reviewer Program – Renewal Application
• Midwife Reviewer Program – Original Application
• Midwife Reviewer Program – Renewal Application

Back to Top

Probationers:

• Petition for Penalty Relief
• Quarterly Declaration

Back to Top