Forms
Consumer:
- Consumer Complaint Form - Fill-In
- Consumer Complaint Form - Spanish Version
- Consumer Response Form - Fill-In
- Request for Public Documents Form
License Verification (LVS):
- Licensing Verification System Subscription Service Form
- Licensing Verification System Subscription Renewal Form
- Request for Copy of 805 Report - Fill-In
- Security Agreement Form - Accessing the Licensing Verification System
- Subscription Service Request - Credentialing Services
Licensees:
- Application for Cancellation of a Fictitious Name Permit
- Application for Continuing Medical Education (CME) Waiver
- 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
- Change of Address - Fill-In
- Direct Dispensing Log
- Disabled Physician Application for Exemption from Payment of Renewal Fee
- Fictitious Name Permit Application
- Fictitious Name Permit Notification of Partnership Change
- Fictitious Name Permit Notification of Shareholder Change
- Fictitious Name Permit Notification of Renewal/Hold Release
- Notification of Name Change - Fill-In
- 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
Applicants:
- Application for Licensure
- Application for Registration as a Contact Lens Dispenser
- Application for Registration as a Dispensing Optician
- Application for Registration as a Nonresident Contact Lens Dispenser
- Application for Registration as a Spectacle Lens Dispenser
- Application for Registration as a Student Research Psychoanalyst
- Application for Research Psychoanalyst Registration
- Fingerprint, Live Scan (Physician and Surgeon applicants only)
Mandatory Reporting:
- Health Facility/Peer Review Reporting Form (805 Report) - Fill-In
- Outpatient Surgery - Patient Death Reporting Form
- Patient Transfer Reporting Form
- Peer Review Body Report Forms (821.5 Report)
- Physician Reporting - Criminal Actions (802 Report)
- 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
- Application for Registration as a Nonresident Contact Lens Dispenser
- Application for Registration as a Spectacle Lens Dispenser
- Application for Registration as a Student Research Psychoanalyst
- Application for Research Psychoanalyst Registration
- Licensed Midwife Disclosure Form
- Registered Dispensing Optician Cancellation of Certificate
