Licensure Forms

Licensure Forms

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Attention Acupuncturists, Athletic Trainers, Chiropractors, Physical Therapists, Physical Therapist Assistants, Physicians, Physician Assistants, Occupational Therapists, Occupational Therapy Assistants, Podiatrists, Radiologic Technologists, and Respiratory Therapists:

The Board has contracted with VeriDoc for expedited license verification to other state medical boards for the above mentioned professions. Verification is convenient and virtually instantaneous. To obtain verification of your Kansas license, go to Veridoc.org to use their secure site any time, day or night. If you have problems with the online verification process, call VeriDoc support at (701)319-6500 or email them at support@veridoc.org. The Board will implement this service for other professions as it becomes available.

Telemedicine Waiver (T.W.)

Athletic Trainer (A.T.)

Independent Certified Nurse Midwife (CNM-I)

Corporate Practice of Medicine (CPM)

Contact Lens Distributor

Doctor of Chiropractic (D.C.)

Doctor of Medicine and Surgery (M.D.)

Doctor of Naturopathic Medicine (N.D.)

Doctor of Osteopathic Medicine and Surgery (D.O.)

Doctor of Podiatric Medicine (D.P.M.)

Licensed Acupuncturist (L.Ac.)

Occupational Therapist (O.T.)

Occupational Therapy Assistant (O.T.A.)

Physician Assistant (P.A.)

Physical Therapist (P.T.)

Physical Therapist Assistant (P.T.A.)

Radiologic Technologist (L.R.T.)

Respiratory Therapist (R.T.)

Telemedicine Waiver (T.W.)

Initial Waiver Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Name Change Form

Third Party Release Form

License Verification Request Form

Non-Kansas Verification Form

Athletic Trainer Practice Protocol Form (AT only)

Active Practice Request Form (PA only)

Active Practice Request Form Instructions

Active Practice Request Form and Written Agreement

Athletic Trainer (A.T.)

Initial Licensing Application (Online)

Initial Licensing Application (Fillable PDF)

Reinstatement Application

Address Change Request Form

Athletic Trainer Practice Protocol Form

Athletic Trainer Practice Protocol Termination Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Allied Health

Designation/Type Change to Military for all Professions

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Corporate Practice of Medicine (CPM)

Initial Certificate of Authorization Application (Fillable PDF)

Third Party Release Form (Fillable PDF)

Certificate of Authorization Renewal

Independent Certified Nurse Midwife (CNM-I)

Initial Licensing Application

Renewal Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Fingerprint Instructions and Waiver Agreement

Kansas Fingerprint Locations List
Please note: This list is not all inclusive. Additional locations may be available in your area.

Name Change Form

Third Party Release Form

Non-Kansas Verification Form

Contact Lens Distributor

Address Change Request Form

Application for Registration to Dispense Contact Lenses By Mail

Reinstatement of Registration to Dispense Contact Lenses By Mail

Credit/Debit Card Payment Authorization Form

Name Change Form

Request for a Duplicate Certificate Form

Doctor of Chiropractic (D.C.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Fingerprint Instructions and Waiver Agreement

Kansas Fingerprint Locations List
Please note: This list is not all inclusive. Additional locations may be available in your area.

Name Change Form

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Healing Arts

Designation/Type Change to Military for all Professions

Unlicensed Rad Tech Data Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Doctor of Medicine and Surgery (M.D.)

On-line Uniform Application (for Physician Licensure only) (Through Federation of State Medical Boards)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Fingerprint Instructions and Waiver Agreement

Kansas Fingerprint Locations List
Please note: This list is not all inclusive. Additional locations may be available in your area.

(Institutional) Initial Licensing Application

(Institutional) Reinstatement Application

Institutional License Certification of Employment

(Limited Permit) Initial Licensing Application

(Limited Permit) Reinstatement Application

(Special Permit) Initial Licensing Application

Name Change Form

Notice of Termination of Supervision of a Physician Assistant Form

(Post Graduate) Initial Licensing Application

Termination of Postgraduate Program

(Post Graduate Supplemental Permit Application) Initial Licensing Application

Resident Active Initial License Application

Resident Active Renewal Application

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Healing Arts

Designation/Type Change to Military for all Professions

Unlicensed Rad Tech Data Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Doctor of Naturopathic Medicine (N.D.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change to Military for all Professions

License Verification Request Form

Non-Kansas Verification Form

Doctor of Osteopathic Medicine and Surgery (D.O.)

On-line Uniform Application (for Physician Licensure only) Through Federation of State Medical Boards

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Fingerprint Instructions and Waiver Agreement

Kansas Fingerprint Locations List
Please note: This list is not all inclusive. Additional locations may be available in your area.

(Institutional) Initial Licensing Application

(Institutional) Reinstatement Application

Institutional License Certification of Employment

(Limited Permit) Initial Licensing Application

(Limited Permit) Reinstatement Application

(Special Permit) Initial Licensing Application

Name Change Form

Notice of Termination of Supervision of a Physician Assistant Form

(Post Graduate) Initial Licensing Application

Termination of Postgraduate Program

(Post Graduate Supplemental Permit Application) Initial Licensing Application

Resident Active Initial License Application

Resident Active Renewal Application

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Healing Arts

Designation/Type Change to Military for all Professions

Unlicensed Rad Tech Data Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Doctor of Podiatric Medicine (D.P.M.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Name Change Form

(Post Graduate) Initial Licensing Application

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Healing Arts

Designation/Type Change to Military for all Professions

Unlicensed Rad Tech Data Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Licensed Acupuncturist (L.Ac.)

Initial Licensing Application

Third Party Release Form

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Designation/Type Change for the Allied Health

Name Change Form

Request for a Duplicate Certificate Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Occupational Therapist (O.T.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

OT - OTA Termination of Supervision

OT - OTA Supervision Agreement

Third Party Release Form

Request for a Duplicate Certificate Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Occupational Therapy Assistant (O.T.A.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

OT - OTA Supervision Agreement

OT - OTA Termination of Supervision

Third Party Release Form

Request for a Duplicate Certificate Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Physician Assistant (P.A.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Active Practice Request Form (Used to notify KSBHA of Physician Supervision of Physician Assistant)

Active Practice Request Form Instructions

Active Practice Request Form and Written Agreement

Letter of Completion

Name Change Form

Notice of Termination of Supervision of a Physician Assistant Form

Third Party Release Form

Request for a Duplicate Certificate Form

Designation/Type Change for the Allied Health

Designation/Type Change to Military for all Professions

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Physical Therapist (P.T.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

PT - PTA Supervision

PT - PTA Termination

Third Party Release Form

Request for a Duplicate Certificate Form

Special Testing Accommodations Request Form (Non-CAPTE Graduates Only)

Designation/Type Change for the Allied Health

Designation/Type Change to Military for all Professions

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Affidavit and Authorization

Physical Therapist Assistant (P.T.A.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

PT - PTA Supervision

PT - PTA Termination

Third Party Release Form

Request for a Duplicate Certificate Form

Special Testing Accommodations Request Form (Non-CAPTE Graduates Only)

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Affidavit and Authorization

Radiologic Technologist (L.R.T.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

Third Party Release Form

Request for a Duplicate Certificate Form

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

Respiratory Therapist (R.T.)

Initial Licensing Application

Reinstatement Application

Address Change Request Form

Credit/Debit Card Payment Authorization Form

Letter of Completion

Name Change Form

Third Party Release Form

Request for a Duplicate Certificate Form

(Student) Initial Licensing Application

Designation/Type Change to Military for all Professions

License Verification Request Form

Expedited Verification of Kansas License to Other State Medical Boards

Non-Kansas Verification Form

800 SW Jackson, Lower Level - Suite A, Topeka, KS 66612
(785) 296-7413; Fax (785) 368-7102
TTY 711 or 1-800-766-3777 voice/TTY