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FORMS

The following forms are posted in Adobe Acrobat Reader (PDF) format.

Licensure Forms
Address Change Request Form
Application Packet Request Form
Athletic Trainer's Responsible Physician and Protocol Form
Credit/Debit Card Payment Authorization Form
Foreign School Verification Request Form
Institutional License Certification of Employment
Name Change Form
Notice of Termination of Supervision of a Physician Assistant Form
Notification or Termination of Supervision of a Physical Therapist Assistant Form
Physician Assistant's Responsible Physician and Drug Prescription Protocol
Request for a Duplicate Certificate Form
Special Accommodations Request Form
Type Change for the Allied Health
Type Change for the Healing Arts
Type Change to Military for all Professions
USMLE Step 3 Application Form
Verification of Kansas License or Registration Form (PT, PTA and AT only)
Verification of Kansas License or Registration Form (MD, DO, DPM, PA, DC, ND, LRT, RT, OT and OTA only)
Verification of Non-Kansas License Registration Form

 

Licensure APPLICATIONS - ON-LINE
New! On-line Uniform Application for Physican Licensure (MD and DO only) Through Federation of State Medical Boards

 

Licensure APPLICATIONS - PAPER FORMS
FILLABLE FORMS (these may take extra time to download). These forms can also be printed, filled out and submitted. NON-FILLABLE FORMS
(AT) Initial Licensing Application (1.33mb) (AT) Initial Licensing Application
(AT) Reinstatement Application (1.31mb) (AT) Reinstatement Application
(Contact Lens Distributor) Application for Registration to Dispense Contact Lenses By Mail (1.11mb) (Contact Lens Distributor) Application for Registration to Dispense Contact Lenses By Mail
(DC) Initial Licensing Application (2.70mb) (DC) Initial Licensing Application
(DC) Reinstatement Application (2.57mb) (DC) Reinstatement Application
(DO) Initial Licensing Application (please refer to the non-fillable form) (DO) Initial Licensing Application
(DO) Reinstatement Application (1.60mb) (DO) Reinstatement Application
(DPM) Initial Licensing Application (3.74mb) (DPM) Initial Licensing Application
(DPM) Reinstatement Application (1.60mb) (DPM) Reinstatement Application
(Institutional) Initial Licensing Application (1.41mb) (Institutional) Initial Licensing Application
(Institutional) Reinstatement Application (1.41mb) (Institutional) Reinstatement Application
(Limited Permit) Initial Licensing Application (1.84mb) (Limited Permit) Initial Licensing Application
(LRT) Initial Licensing Application (1.21mb) (LRT) Initial Licensing Application
(LRT) Reinstatement Application (1.20mb) (LRT) Reinstatement Application
(MD) Initial Licensing Application (please refer to the non-fillable form) (MD) Initial Licensing Application
(MD) Reinstatement Application (1.60mb) (MD) Reinstatement Application
(ND) Initial Licensing Application (2.01mb) (ND) Initial Licensing Application
(ND) Reinstatement Application (116kb) (ND) Reinstatement Application
(OT) / (OTA) Initial Licensing Application (1.22mb) (OT) / (OTA) Initial Licensing Application
(OT) / (OTA) Reinstatement Application (1.20mb) (OT) / (OTA) Reinstatement Application
(PA) Initial Licensing Application (1.42mb) (PA) Initial Licensing Application
(PA) Reinstatement Application (1.41mb) (PA) Reinstatement Application
(Post Graduate) Initial Licensing Application (1.42mb) (Post Graduate) Initial Licensing Application
(Post Graduate Supplemental Permit Application) Initial Licensing Application (1.42mb) (Post Graduate Supplemental Permit Application) Initial Licensing Application
(PT) / (PTA) Initial Licensing Application (1.33mb) (PT) / (PTA) Initial Licensing Application
(PT) / (PTA) Reinstatement Application (1.41mb) (PT) / (PTA) Reinstatement Application
(RT) Initial Licensing Application (1.21mb) (RT) Initial Licensing Application
(RT) Reinstatement Application (1.20mb) (RT) Reinstatement Application
(Student RT) Initial Licensing Application (1.71mb) (Student RT) Initial Licensing Application

 

Licensure RENEWAL Forms
FILLABLE FORMS (these may take extra time to download). These forms can also be printed, filled out and submitted. NON-FILLABLE FORMS
(OT) Renewal (878 kb) -available 2-15-2012 (OT) Renewal - available 2-15-2012
(OTA) Renewal (878 kb) -available 2-15-2012 (OTA) Renewal - available 2-15-2012
(RT) Renewal (878 kb) -available 2-15-2012 (RT) Renewal - available 2-15-2012

 

Legal Forms
Complaint Form

 

Healthcare Facility Forms
Report of Adverse Findings Form (fillable) - (Form can be completed and then printed )
Report of Adverse Findings Form (non-fillable) - (Form is only a printable form)
Closed Claim Report Form - (Form is only a printable form)

 

Administrative Forms
Credit/Debit Card Payment Authorization Form
Query Order Form

 

Disciplinary Forms (if you answered yes to disciplinary questions please fill out the appropriate form)
Professional Liability Claim Award or Settlement
Felony or Class A Misdemeanor
Licensing Agency Action
License Denial
Hospital Privileges or Peer or Professional Association Review
Impairments
Licensing Agency, State or Governmental Agency Investigation

Forms are posted in Adobe Acrobat Reader (PDF) format.

Graphic Logo for Adobe Acrobat ReaderYou may download a FREE version of the Acrobat Reader here

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Kansas State Board of Healing Arts
800 SW Jackson, Lower Level - Suite A, Topeka, KS 66612
Phone: (785) 296-7413  -   Toll Free: 1-888-886-7205  -   Fax: (785) 296-0852

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