Consumers:

• Consumer Complaint Form
  • Download: EN | SP
• Consumer Response Form
• Request for Certified Public Documents Form
• Authorization for Release of Information for the Subject of the Complaint
• Physician/Provider/Facility Authorization for Release of Information
• Kaiser Authorization for Release of Information

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Applicants:

• Physicians and Surgeons

  • Postgraduate Training License (PTL) Application Forms [+]
    • Application for a Postgraduate Training License Information & Checklist
    • Application for a Postgraduate Training License (Forms PTL1-PTL5)
    • Live Scan Service Form for Electronic Fingerprints
    • Explanation for Application Question (Form EXP)
    • Timeline of Activities (Form TOA)
    • Certificate of Medical Education (Form MED)
    • Certificate of Completion of ACGME/RCPSC/CFPC Postgraduate Training (Form PTA/B)
    • Postgraduate Training License Enrollment Form (Form EF)
  • Physician's and Surgeon's License Application Forms [+]
    • Application for a Physician and Surgeon License Information & Checklist
    • Application for a Physician and Surgeon License (Forms L1A-L1F)
    • Live Scan Service Form for Electronic Fingerprints
    • Explanation for Application Question (Form EXP)
    • Timeline of Activities (Form TOA)
    • Certificate of Medical Education (Form MED)
    • Certificate of Completion of ACGME/RCPSC/CFPC Postgraduate Training (Form PTA/B)
    • Current Postgraduate Training Verification (Form CTV)
    • Limited Practice License (Form LPL), if applying for Limited Practice status
    • Certificate of Completion of CODA Postgraduate Training (Form CODA1-CODA2)
  • Transition from a Postgraduate Training License (PTL) to a Physician’s and Surgeon’s License Application Forms (PTL Holders Only) [+]
    • Application to Transition from a PTL to a Physician’s and Surgeon’s License Information & Checklist
    • Application to Transition from a PTL to a Physician’s and Surgeon’s License (Forms TF1-TF4)
    • Live Scan Service Form for Electronic Fingerprints
    • Explanation for Application Question (Form EXP)
    • Certificate of Medical Education (Form MED)
    • Certificate of Completion of ACGME/RCPSC/CFPC Postgraduate Training (Form PTA/B)
    • Current Postgraduate Training Verification (Form CTV)
    • Limited Practice License (Form LPL), if applying for Limited Practice status
    • Certificate of Completion of CODA Postgraduate Training (Form CODA1-CODA2)
  • Other Forms and Information
    • Notarized Signatory Page (Form L1F), Required for Physician's and Surgeon's License Applications submitted using the BreEZe online application system
    • Notarized Signatory Page (Form TF4), Required for Transition Applications submitted using the BreEZe online application system
    • Notarized Signatory Page (Form PTL5), Required for PTL Applications submitted using the BreEZe online application system
    • Program Status Update/Change (Form PSU)
    • Translation of International Academic Credentials
    • Notification of Name Change
    • Applicant Address Change Request
    • Fictitious Name Permit Application
    • Direct Online Certification Submission (DOCS) Flyer and Form

• Midwives

  • Application for Midwifery License
  • Live Scan Service Form for Electronic Fingerprints, for Midwives applicants only

• Polysomnography

  • Application for Polysomnography Registration
  • Live Scan Service Form for Electronic Fingerprints, for Polysomnography applicants only

• Research / Student Research Psychoanalysts

  • Application for Research/Student Research Psychoanalyst
  • Live Scan Service Form for Electronic Fingerprints, for Research/Student Research Psychoanalysts applicants only

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License Verification System (LVS):

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

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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

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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)
• Health Facility Reporting Form (805.8 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

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Expert Reviewer:

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

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Probationers:

• Petition for Penalty Relief
• Quarterly Declaration

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