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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

FAQ

Instructions and Application for Licensed Acupuncturist, American Graduates

Instructions and Application for Licensed Acupuncturist, Non-American Graduates

Form A, Claims History Sheet 

Form B, Activity Questionnaire

Form C, Clearance from Other State Boards

Form L, Proof of Professional Education

NCCAOM Certification Form

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@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

Instructions for Assistant Behavior Analyst applicants

 

Athletic Trainer

FAQ

Instructions and Application for a license to Practice as an Athletic Trainer

Athletic Trainer - Form A

Athletic Trainer - Form B

Athletic Trainer - Form C

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@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.

Behavior Analyst - Form B

Instructions for Assistant Behavior Analyst applicants

 

Chiropractic

Applications for a license to practice Chiropractic are now accepted online.
Click here to begin the online application process.

Online application Instructions and Form B - Hospital/Employment Activity Questionnaire

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

 

Internship/Residency/Fellowship for Approved Programs

Instructions and Application for a Virginia Internship/Residency

Regulations Regarding Interns/Residents

Residency Memorandum (Form A)

Certificate of Professional Education (Form B)

Transfer Request Form

 

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.

View the instructions and forms for Graduates of US or Canadian Medical Schools

View the instructions and forms for Graduates of Foreign Medical Schools

Form B - Hospital/Employment History Questionnaire

Form H - Report of Clinical Rotations


Reinstatement of a Medicine & Surgery License - Please contact Delores Cousins at (804) 367-4471 or medbd@dhp.virginia.gov for a reinstatement licensure application packet.

Disciplinary Reinstatement of a Medicine & Surgery License - Please contact Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

 

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Midwifery

FAQ

Instructions and Application for License to Practice as a Licensed Midwife

Form A - Claims History

Form B

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@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.

FAQ

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

 

Occupational Therapy Assistant

Applications for a license to practice as an Occupational Therapy Assistant are now accepted online.
Click here to begin the online application process.

FAQ

Online application Instructions and Form B - Employment Activity Questionnaire

Board Approved Practice

 

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

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Physician Assistant

FAQ

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

Application to Take the ARRT Fluoroscopy Examination

Practice Agreement for Physician Assistant and Instructions

Alternate Supervisors Form

Prescriptive Authority Request Form

Addendum to Practice of Physician Assistant Duties

Physician Assistant Invasive Procedures Protocol

Disciplinary Reinstatement of a Physician Assistant License - Please contact Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

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Radiologic Technologist

Applications for a license to practice as a Radiologic Technologist are now accepted online.
Click here to begin the online application process.

FAQ

Online application Instructions and Forms for Radiologic Technologist

Form C - Clearance from other Jurisdictions

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

Radiologic Technologist-Limited

Applications for a license to practice as a Radiologic Technologist-Limited are now accepted online.
Click here to begin the online application process.

FAQ

Online application Instructions and Forms for Radiologic Technologist

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

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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.

FAQ

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 Tamika Hines for licensure package at (804) 367-4513 or tamika.hines@dhp.virginia.gov

 

Surgical Technologists and Surgical Assistants

The 2014 Session of the General Assembly passed legislation that authorizes the Board to register individuals that qualify as surgical technologists and surgical assistants. The Board will be prepared to begin registration sometime after July 1, 2014. It is suggested that you check this site weekly beginning in August 2014 to see if the registration process is in place.

 

University Limited/Full-time Faculty/Fellowship for Foreign Graduates

Instructions for Completing an Application for a Limited License to Practice Medicine as a Full-time Faculty Member or as a Full-time Fellow

Application for a Limited License to Practice Medicine as a Full-time Faculty Member or as a Full-time Fellow

Regulations Regarding Limited Licenses to Foreign Medical Graduates

ECFMG (Form G)

Volunteer Practice Forms

Volunteer Practice Sponsor Form

Application for Registration for Volunteer Practice

Application for Restricted Volunteer License (Doctor of Medicine, Osteopathic Medicine, Podiatry or Chiropractic

Application for Restricted Volunteer License (Licensed Acupuncturist, Physician Assistant, Respiratory Care Practitioner, Occupational Therapist, Radiologic Technologist or Radiologic Technologist Limited)

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

 

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