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 Beulah Archer for licensure package at (804) 367-3051 or Beulah.Archer@dhp.virginia.gov
Disciplinary Reinstatement of an Acupuncturist License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
Assistant Behavior Analyst
Applications for a license to practice as an Assistant Behavior Analyst are now accepted online.
Click
here to begin the online application process.
Assistant Behavior Analyst - Form B
Athletic Trainer
Instructions and Application for a license to Practice as an Athletic Trainer
Application for Provisional License
Reinstatement of an Athletic Trainer License - Please contact Bradley Verry for licensure package at (804) 367-4613 or bradley.verry@dhp.virginia.gov
Disciplinary Reinstatement of an Athletic Trainer License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
Behavior Analyst
Applications for a license to practice as a Behavior Analyst are now accepted online.
Click
here to begin the online application process.
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 ShaRon Clanton for licensure package at (804) 367-4501 or ShaRon.Clanton@dhp.virginia.gov
Disciplinary Reinstatement of a Chiropractor License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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
Apply Online
Applications for Medicine and Surgery license (American and International Medical School Graduates) are now accepted online. Do not use this application if you need an Interns/Residency/Fellowship license. Click here to begin the online application process and pay the $302 application fee.
Graduates of American (territories included) and Canadian Medical Schools:
Graduates of Foreign Medical Schools:
Reinstatement of a Medicine & Surgery License - Please contact the Board at (804) 367-4600 or medbd@dhp.virginia.gov for a reinstatement licensure application packet.
Disciplinary Reinstatement of a Medicine & Surgery License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
Midwifery
Instructions and Application for License to Practice as a Licensed Midwife
Form C, Jurisdiction Clearance
Reinstatement of a License to Practice as a Midwife - Please contact Beulah Archer for licensure package at (804) 367-3051 or Beulah.Archer@dhp.virginia.gov
Disciplinary Reinstatement of a License to Practice as a Midwife - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
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
Applications for a license to practice Occupational Therapy are now accepted online.
Click
here to begin the online application process.
Form B, Activity Questionnaire - Initial Application
Reinstatement of an Occupational Therapy License - Please contact Bradley Verry for licensure package at (804) 367-4613 or bradley.verry@dhp.virginia.gov
Disciplinary Reinstatement of an Occupational Therapy License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
Occupational Therapy Assistant
Instructions and Application for a License to Practice as an Occupational Therapy Assistant
Osteopathy
Apply Online
Applications to Practice Osteopathic Medicine are now accepted online.
Click
here to begin the online application process.
Form B - Hospital/Employment History Questionnaire
Form D - Request for Physician Profile
Reinstatement of an Osteopathic Medicine License - Please contact Pam Smith for licensure package at (804) 367-4570 or Pam.Smith@dhp.virginia.gov
Disciplinary Reinstatement of an Osteopathic Medicine License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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
Prescriptive Authority Request Form
Addendum to Practice of Physician Assistant Duties
Physician Assistant Invasive Procedures Protocol
Physician Assistant Volunteer License
Reinstatement of a Physician Assistant License - Please contact ShaRon Clanton for licensure package at (804) 367-4501 or ShaRon.Clanton@dhp.virginia.gov
Disciplinary Reinstatement of a Physician Assistant License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
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
Disciplinary Reinstatement of a Podiatry License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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 Beulah Archer for licensure package at (804) 367-3051 or Beulah.Archer@dhp.virginia.gov
Disciplinary Reinstatement of a Radiologic Technologist License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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 Beulah Archer for licensure package at (804) 367-3051 or Beulah.Archer@dhp.virginia.gov
Disciplinary Reinstatement of a Radiologic Technologist-Limited License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov
Radiologist Assistant
Applications for a license to practice as a Radiologist Assistant are now accepted online.
Click here to begin the online application process.
Respiratory Care Practitioner
Applications for a license to practice as a Respiratory Care Practitioner are now accepted online.
Click
here to begin the online application process.
Form B, Activity Questionnaire
Reinstatement of a Respiratory Care Practitioner License - Please contact Bradley Verry for licensure package at (804) 367-4613 or bradley.verry@dhp.virginia.gov
Disciplinary Reinstatement of a Respiratory Care Practitioner License - Please contact Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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