Verification of Licensure Status A verification of ...
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HEALTH
HEALTH REGULATION AND LICENSING ADMINISTRATION
Verification of Licensure Status
A verification of licensure status for a health care practitioner or health facility can be obtained two
ways and the fee is $34.00 payable to the DC Treasurer. The processing and mailing of verification
requests may take 20 business days and you will be notified, by email, when your verification has been
mailed.
A) If you have a form from the jurisdiction or institution that must be completed by the DC
Department of Health, complete the form below, attach the verification request form supplied
by the other state board, the required fee and mail it to our office. If the jurisdiction or
institution has an electronic verification system, please provide the email information for
submission.
B) If you want a letter to be sent to a particular entity, complete the form below, attach the
required fee, and mail it to our office.
MAILING ADDRESS FOR VERIFICATION REQUESTS
District of Columbia Department of Health
Health Regulation and Licensing Administration
899 North Capitol Street, N.E. First Floor
Washington, DC 20002
NURSES ONLY may contact the RN/LPN licensure verification access system at .
Contact Information
District of Columbia Department of Health
Health Regulation and Licensure Administration
Phone number: 877-672-2174
Office hours: Monday ¨C Friday 8:30am ¨C 4:30pm
Location: 899 North Capitol Street, N.E. First Floor Washington, DC 20002
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HEALTH
HEALTH REGULATION AND LICENSING ADMINISTRATION
REQUEST OF VERIFICATION OF LICENSURE STATUS FORM
(Please print legibly)
NAME OF THE BOARD YOU ARE REQUESTING THE VERIFICATION FROM:
_____________________________________________________________
Licensee Information:
HOW WERE YOU LICENSED: ENDORSEMENT ____
EXAMINATION ____
LICENSE NUMBER (if known):______________ DATES OF LICENSURE (if known): ________________
SOCIAL SECURITY #: __________________
YOUR NAME (if you used another name when you were licensed indicate that name):
_____________________________________________________________________
Last Name
First Name
Middle Name
YOUR ADDRESS:_______________________________________________________________________
City: ________________________
State: ______________
YOUR TELEPHONE NUMBER: _________________
Zip Code:___________
Email Address: ________________________
I hereby authorize the DC Department of Health to release any information, favorable or otherwise against my
license to the state licensing board/entity or person listed below.
Signature: _______________________________________
Date: ________________________
Mailing Information:
IF YOU HAVE A FORM FROM A JURISDICTION OR INSTITUION ATTACH THE FORM, THE PAYMENT AND
MAIL IT TO US.
NAME AND ADDRESS OF WHERE YOU WANT THE VERIFICATION SENT:
State Board Name: __________________________________________________________________
Mailing Address: ____________________________________________________________________
City:____________________________
State:________________
Zip Code:_________
................
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