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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 Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov

Assistant Behavior Analyst

Due to the expiration of the emergency regulations for Behavior Analysts and Assistant Behavior Analysts, the Board is not able to accept your application at this time. The new regulations will be effective on May 7th, 2014. Please return at that time to complete your application. Thank you, The Virginia Board of Medicine.

 

 

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 Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov

 

Behavior Analyst

Due to the expiration of the emergency regulations for Behavior Analysts and Assistant Behavior Analysts, the Board is not able to accept your application at this time. The new regulations will be effective on May 7th, 2014. Please return at that time to complete your application. Thank you, The Virginia Board of Medicine.

 

 

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 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

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

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 Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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 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.

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 Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@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 C – Jurisdiction Clearance – License Verification

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

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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 AART 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

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

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Radiologic Technologist

FAQ

Instructions and Application for Licensure as a Radiologic Technologist

Form A, Claims History Sheet

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

FAQ

Instructions and Application for Licensure as a Radiologic Technologist-Limited

Form A, Claims History Sheet

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

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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 Jennie Wood for licensure package at (804) 367-4571 or jennie.wood@dhp.virginia.gov

 

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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