TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF MEDICINE

Forms

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)