REGULATIONS
Vol. 40 Iss. 16 - March 25, 2024

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
BOARD OF MEDICINE
Chapter 120
Forms

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF MEDICINE

Forms

REGISTRAR'S NOTICE: Forms used in administering the regulation have been filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 201 North Ninth Street, Fourth Floor, Richmond, Virginia 23219.

Titles of Regulations: 18VAC85-20. Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic.

18VAC85-40. Regulations Governing the Practice of Respiratory Therapists.

18VAC85-50. Regulations Governing the Practice of Physician Assistants.

18VAC85-80. Regulations Governing the Practice of Occupational Therapy.

18VAC85-101. Regulations Governing the Practice of Radiologic Technology.

18VAC85-110. Regulations Governing the Practice of Licensed Acupuncturists.

18VAC85-120. Regulations Governing the Licensure of Athletic Trainers.

18VAC85-130. Regulations Governing the Practice of Licensed Midwives.

18VAC85-140. Regulations Governing the Practice of Polysomnographic Technologists.

18VAC85-150. Regulations Governing the Practice of Behavior Analysis.

18VAC85-160. Regulations Governing the Licensure of Surgical Assistants and Certification of Surgical Technologists.

18VAC85-170. Regulations Governing the Practice of Genetic Counselors.

Agency Contact: Erin Barrett, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 367-4688, or email erin.barrett@dhp.virginia.gov.

FORMS (18VAC85-20)

Application to Practice Medicine, Osteopathic Medicine, Chiropractic, and Podiatry, online application available at https://www.license.dhp.virginia.gov/apply/

Application to Practice Medicine, by endorsement, online application at https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice Medicine in Virginia for Graduates of Allopathic Medical Schools and Osteopathic Medical Schools (rev. 12/2017)

Instructions for Completing an Application to Practice Chiropractic in Virginia (rev. 12/2017)

Instructions for Completing an Application for Licensure by Endorsement (rev. 8/2020)

Instructions for Completing Podiatric Medicine Application (rev. 12/2017)

Form B, Activity Questionnaire (rev. 7/2017)

Form A, Intern/Resident, Memorandum from Associate Dean of Graduate Medical Education or Program Director (rev. 8/2007)

Form B, Intern/Resident Certificate of Professional Education (rev. 8/2007)

Form G, Intern Resident, Request for Status Report of ECFMG Certification (eff. 8/2007)

Intern/Resident, Transfer Request (rev. 6/2016)

Instructions for Completing an Application for a Limited License to Foreign Medical Graduates Pursuant to § 54.1-2936 (rev. 8/2007)

Application for a Limited License to Foreign Medical Graduates Pursuant to 54.1-2936 (rev. 8/2007)

Form A, MD Reinstatement, Claims History Sheet (rev. 9/2009)

Reinstatement of a Podiatry License – Please contact Pam Smith for licensure package at (804) 367-4570 or pam.smith@dhp.virginia.gov

MD/DO Reinstatement Instructions and Application for MD and DO licenses in EXPIRED status for more than two years ONLY (rev. 8/2020)

Instructions for Reinstatement of a Chiropractic Licensure Application (rev. 4/2018)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Application for Restricted Volunteer License (rev. 12/2007)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-40)

Instructions for Completing an Application to Practice as a Respiratory Therapist Therapy in Virginia (rev. 5/2022)

Form B Supplemental Form (rev. 9/2018)

Application for Registration for Volunteer Practice (8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Application for Restricted Volunteer License (rev. 8/2015)

Continued Competency Activity and Assessment Form (rev. 4/2000)

Application to Reactivate an Inactive License for a Respiratory Therapist (rev. 5/2019)

Instructions and Application for Reinstatement of a Respiratory Therapist License (4/2018)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-50)

Application for a License to Practice as a Physician Assistant, by endorsement or examination, online form available at: https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice as a Physician Assistant in Virginia (rev. 11/2017)

Form B, Employment History (rev. 7/2017)

Form B, Supplemental Form (rev. 9/2018)

ARRT Fluoroscopy Examination Application for a Physician Assistant (rev. 2/2014)

Physician Assistant Authorization to Use Fluoroscopy (rev. 1/2014)

Practice Agreement as a Physician Assistant (PA) (rev. 10/2019)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Application for Restricted Volunteer License (rev. 8/2015)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-80)

Applications for a License to Practice Occupational Therapy or as an Occupational Therapy Assistant, available online at https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice as an Occupational Therapist/Occupational Therapy Assistant in Virginia (rev. 12/2017)

Supplemental Form to Form B (rev. 9/2018)

Instructions and Application for Reinstatement of a License to Practice as an Occupational Therapist/Occupational Therapy Assistant (rev. 4/2018)

Application to Reactivate an Inactive License for an Occupational Therapist Assistant Pursuant to Virginia Regulations 18VAC85-80-72 (rev. 5/2019)

Application to Reactivate an Inactive License for an Occupational Therapist Pursuant to Virginia Regulations 18VAC85-80-72 (rev. 1/2018)

Supervised Occupational Therapy Services (lapse between two to six years) (rev. 5/2017)

Supervised Occupational Therapy Services (lapse six years or more) (rev. 5/2017)

Continued Competency Activity and Assessment Form (rev. 4/2000)

Application for Restricted Volunteer License (rev. 8/2015)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-101)

Application to Practice as a Radiologic Technologist, Limited Radiologic Technologist, or Radiologist Assistant, online application available at https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice as a Radiologic Technologist in Virginia (rev. 12/2017)

Instructions for Completing an Application to Practice as a Limited Radiologic Technologist in Virginia (rev. 12/2017)

Instructions for Completing an Application to Practice as a Radiologist Assistant in Virginia (rev. 12/2017)

Form B, Activity Questionnaire (rev. 7/2017)

Supplemental Form to Form B (rev. 9/2018)

Form C, Radiologic Technologist/Radiologist Assistant, Clearance from Other States (rev. 11/2010)

Form B, Certificate of Professional Education (rev. 8/2007)

Instructions and Application for Reinstatement of a License to Practice as a Radiologic Technologist/Limited Radiologic Technologist (rev. 12/2019)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 7/2018)

Continued Competency Activity and Assessment Form (eff. 7/2008).

License Verification Request (rev. 2/2024)

FORMS (18VAC85-110)

Instructions for Completing an Application to Practice as an Acupuncturist in Virginia (rev. 3/2017)

Form A, Claims History (rev. 11/2010)

Form B, Employment History (rev. 7/2017)

Form C, Clearance from Other State Boards (rev. 11/2010)

Form L, Certification Certificate of Professional Education (rev. 8/2007)

Verification of NCCAOM Certification (rev. 3/2008)

Recommendation for Examination by a Physician (rev. 11/2006)

License Verification Request (rev. 2/2024)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Instructions and Application for Reinstatement of an Acupuncture Licensure (rev. 4/2018)

Application to Reactivate an Inactive License for a Licensed Acupuncturist (rev. 1/2018)

FORMS (18VAC85-120)

Application for a License to Practice as an Athletic Trainer, online form available at https://www.dhp.virginia.gov/medicine/medicine_forms.htm

Instructions for Completing an Athletic Trainer Licensure Application (12/2017)

Form B Supplemental Form (rev. 9/2018)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Instructions and Application for Reinstatement of an Athletic Trainer Licensure (rev. 4/2018)

Certificate of Professional Education (rev. 8/2007)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-130)

Instructions for Completing a Licensed Midwife Application (rev. 3/2017)

Form A, Claims History (rev. 11/2010)

Form B, Activity Questionnaire (rev. 7/2017)

Form B Supplemental Form (rev. 9/2018)

Form C, Jurisdiction Clearance (rev. 11/2010)

Instructions and Application for Reinstatement of a License to Practice as a Certified Professional Midwife (CPM) (rev. 4/2018)

Application to Reactivate an Inactive License for a Licensed Midwife (rev. 5/2019)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-140)

Application to Practice as a Polysomnographic Technologist in Virginia, online application at https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice as a Polysomnographic Technologist in Virginia (rev. 12/2017)

Form B, Employment Activity (rev. 7/2017)

Form B Supplemental Form (rev. 09/2018)

Form C, Verification Form (rev. 8/2013)

Application to Reactivate an Inactive License for a Polysomnographic Technologist (rev. 10/2018)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-150)

Application to Practice as a Behavior Analyst or Assistant Behavior Analyst, online form available at https://www.dhp.virginia.gov/medicine/medicine_forms.htm

Instructions for Completing an Application to Practice as a Board Certified Behavior Analyst/Assistant Behavior Analyst in Virginia (rev. 12/2017)

Form B Supplemental Form (rev. 9/2018)

Instructions and Application for Reinstatement of a Behavior Analyst or Assistant Behavior Analyst Licensure (rev. 4/2018)

Application to Reactivate an Inactive License for a Behavior Analyst or Assistant Behavior Analyst (rev. 1/2018)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-160)

Instructions for Completing an Application to Practice as a Licensed Surgical Assistant (rev. 10/2020)

Instructions for Completing an Application to Practice as a Certified Surgical Technologist (rev. 5/2022)

License Verification Request (rev. 2/2024)

FORMS (18VAC85-170)

Instructions for Completing an Application to Practice as a Genetic Counselor, available online at https://www.dhp.virginia.gov/medicine/medicine_forms.htm#Genetic

Instructions for Completing an Application to Practice Genetic Counseling in Virginia (rev. 12/2017)

Instructions for Completing an Application for a Temporary License to Practice in "Active Candidate Status" to Practice Genetic Counseling in Virginia (rev. 6/2017)

Form B, Employment History (rev. 7/2017)

Form B Supplemental Form (rev. 9/2018)

Continued Competency Activity and Assessment Form (eff. 6/2017)

Genetic Counselor Reinstatement Instructions and Application (eff. 2/2023)

License Verification Request (rev. 2/2024)

VA.R. Doc. No. R24-7816; Filed March 05, 2024