Virginia Board of Medicine
Forms & Applications
The below documents are in Microsoft Word format. If you do not have Microsoft Word, you can get the Microsoft® Word Viewer 97/2000 to view and print DHP's documents.
Acupuncturist
Instructions and Application for Licensed Acupuncturist, American Graduates
Instructions and Application for Licensed Acupuncturist, Non-American Graduates
Form B, Activity Questionnaire
Form C, Clearance from Other State Boards
Form L, Proof of Professional Education
Reinstatement of an Acupuncturist License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Athletic Trainer
Instructions and Application for a license to Practice as an Athletic Trainer
Reinstatement of an Athletic Trainer License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Chiropractic
Form B, Hospital/Employment Activity Questionnaire
Form C, Jurisdiction Clearance
Form L - Certificate of Professional Education
Requirement for SPEC Transcript (pdf File)
Reinstatement of a Chiropractic License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Internship/Residency/Fellowship for Approved Programs
Instructions and Application for a Virginia Internship/Residency
Regulations Regarding Interns/Residents
Certificate of Professional Education (Form B)
Medicine and Surgery
Graduates of American (territories included) and Canadian Programs:
Instructions and Application to Practice Medicine & Surgery for Graduates of Approved Programs
Form B, Hospital/Employment Activity Questionnaire
Form C, Jurisdiction Clearance
Form E, FSMB Disciplinary Inquiry
Form L, Certificate of Professional Education
Request for Examination and Board Action History Report (EBAHR) (link to Federation of State Medical Boards' website)
Request for Endorsement of National Board of Medical Examiners (NBME) Certification (pdf File)
Graduates of Foreign (Non-Approved) Programs:
Instructions and Application to Practice Medicine & Surgery for Graduates of Non-Approved Programs
Form B, Hospital/Employment Activity Questionnaire
Form C, Jurisdiction Clearance
Form E, FSMB Disciplinary Inquiry
Form G, ECFMG Certification Status Request
Form H - Report of Clinical Rotations
Request for Examination and Board Action History Report (EBAHR) (link to Federation of State Medical Boards' website)
Request for Endorsement of National Board of Medical Examiners (NBME) Certification (pdf File)
Reinstatement of a Medicine & Surgery License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Application for USMLE Step 3:
As of February 18th, 2003, the Board of Medicine for the Commonwealth of Virginia will no longer provide applications for the USMLE Step 3 Examination. Applications provided prior to that date will be honored and processed according to the guidelines associated with the application until April 15th, 2003. Applications received after April 15th, 2003 may be returned.
Candidates who wish to apply to take the USMLE Step 3 Examination must contact the Federation of State Medical Boards. Applications and related information can be found at www.fsmb.org.
Midwifery
Instructions and Application for License to Practice as a Licensed Midwife
Form C, Jurisdiction Clearance
Continuing Education
MD, DO, DPM & DC - Continued Competency Form and Instructions
Occupational Therapy - Continued Competency Form and Instructions
Radiologic Technology - Continued Competency Form and Instructions
Respiratory Care Practitioner - Continued Competency Form and Instructions
Occupational Therapy
Instructions and Application for a License to Practice Occupational Therapy
Form A, Claims History Sheet - Initial Application
Form B, Activity Questionnaire - Initial Application
Form C, Clearance from Other State Boards - Initial Application
Form L, Certificate of Professional Education
NBCOT Verification of Certification Request Form (pdf File)
Reinstatement of an Occupational Therapy License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Osteopathy
Instructions and Application to Practice Osteopathic Medicine in the Commonwealth of Virginia
Form B - Hospital/Employment History Questionnaire
Form C - Jurisdiction Clearance
Form D - AOA Physician Profile Request
Form L - Certificate of Professional Education
National Board of Osteopathic Medical Examiners Transcript Request Form (pdf File)
Request for Examination and Board and Action History Report (EBAHR) (link to Federation of State Medical Boards' website)
Reinstatement of an Osteopathic Medicine License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Physician Assistant
Instructions and Application for a License as a Physician Assistant
Form L, Certificate of Physician Assistant Education
Form C, Clearance from other Jurisdictions
Form B, Employment/Activity Questionnaire
Instructions and Application for Practice as a Physician Assistant
List of Schools with Pre-Approved Pharmacology
Prescriptive Authority Request Form
Addendum to Practice of Physician Assistant Duties
Physician Assistant Invasive Procedures Protocol
Physician Assistant Volunteer License
Podiatry
Instructions and Application for License to Practice Podiatry
Continued Competency Activity and Assessment Form
Form A, Claims History Sheet - Endorsement
Form B, Activity Questionnaire - Endorsement
Form C, Clearance from Other State Boards - Endorsement
PMLEXIS Certificate of Education (Form L)
Form H, Federation of Podiatric Medical Boards Report
Reinstatement of a Podiatry License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Radiologic Technologist
Instructions and Application for Licensure as a Radiologic Technologist
Form B, Activity Questionnaire
Form C, Clearance from Other State Boards
Form E, Certification Request from American Registry of Radiologic Technologists
Form F, Traineeship Application Statement of Authorization
Form L, Proof of Professional Education
Reinstatement of a Radiologic Technologist License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Radiologic Technologist-Limited
Instructions and Application for Licensure as a Radiologic Technologist-Limited
Form B, Activity Questionnaire
Form C, Clearance from Other State Boards
Form TE, Radiologic Technologist Limited training application while awaiting exam
Forms TA(1) and TA(2) Radiologic Technologist Limited training application for abdomen
Forms TC(1) and TC(2) Radiologic Technologist Limited training application for Clinical Training
Reinstatement of a Radiologic Technologist-Limited License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Respiratory Care Practitioner
Instructions and Application for Licensure as a Respiratory Care Practitioner
Form B, Activity Questionnaire
Form C, Clearance from Other State Boards
Form L, Certificate of Professional Education
Reinstatement of a Respiratory Care Practitioner License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
University Limited/Full-time Faculty/Fellowship for Foreign Graduates
Regulations Regarding Limited Licenses to Foreign Medical Graduates
Volunteer Practice Forms
Volunteer Practice Sponsor Form
Application for Registration for Volunteer Practice
Miscellaneous Forms
Application for a Duplicate Wall Certificate
Licensed Acupuncturist - Recommendation for Examination by a Physician
Request for Removal of Notice/Order
Application to Reactivate an Inactive License for an MD, DO, DPM or DC
Application to Reactivate an Inactive License for a Licensed Midwife
Application to Reactivate an Inactive License for a Licensed Acupuncturist
Application to Reactivate an Inactive License for an Occupational Therapist
Application to Reactivate an Inactive License for a Physician Assistant
Application to Reactivate an Inactive License for a Respiratory Care Practitioner
Application to Reactivate an Inactive License for a Radiologist Technologist
Application to Reactivate an Inactive License for a Radiologist Technologist-Limited