License Verification Request Out-of-State Telehealth Provider
License Verification Request Out-of-State Telehealth Provider
Completed verifications must be mailed directly from the verifying agency to: Telehealth 4052 Bald Cypress Way, Bin C-11 Tallahassee, FL 32399-1708
Part I: To Be Completed By Applicant
Name: _______________________________________________________________________________________
Last/Surname
First
Middle
Address: _____________________________________________________________________ _______
Street/P.O. Box
Apt. No.
_______________________ ______________ _________
City
State
ZIP
Profession: ________________________ License Number: _________________ State: ____________
I hereby authorize release of any information regarding my licensure status to the Division of Medical Quality Assurance.
Applicant's Signature: _________________________________________________ Date: ___________
MM/DD/YYYY
Part II: To Be Completed By State Licensing Agency
All verifications must be in English and meet the following criteria:
Typed on an official state form or letterhead Include an official board seal Signature and title of state board official
The following information must be included in all verifications:
Licensee name License number State or jurisdiction of licensure Licensure status Whether license is in good standing Date of issuance/expiration Licensure method (examination, grandfathering, reciprocity/endorsement) If this license has ever been encumbered (denied, revoked, suspended, surrendered, limited, placed on
probation) please provide certified copies of documentation regarding the action taken with the completed license verification.
DH5041-MQA-07/2019, Rule 64B-9.008, F.A.C.
Page 1 of 1
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- board of podiatric medicine license verification request
- prevention of medical errors for florida healthcare professionals
- access to online license system through the ahca web portal florida
- certification of address
- license verification form florida department of health
- verification of clinical experience
- license verification request florida board of nursing
- application for out of state telehealth provider registration
- licensure data download guide
- license verification request
Related searches
- tea out of state certification
- texas out of state teaching license
- texas out of state teacher certification
- out of state tuition california
- temple out of state cost
- out of state garnishment laws
- out of state wage garnishment
- dmv ct out of state transfer
- ct out of state license
- ct dmv out of state registration
- arkansas out of state hunting license
- out of state cna transfer