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Licensing Forms

Sports Waiver (S.W.)

Telemedicine Waiver (T.W.)

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.)

Athletic Trainer (A.T.)

Corporate Practice of Medicine (CPM)

Independent Certified Nurse Midwife (CNM-I)

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

Doctor of Chiropractic (D.C.)

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.)

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.)
Postgrad Training Verification
- Postgraduate Training Year 3 In Progress
- Postgraduate Training Verification (UA Form #3) Completed
(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.)

Doctor of Naturopathic Medicine (N.D.)

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

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.)
Postgrad Training Verification
- Postgraduate Training Year 3 In Progress
- Postgraduate Training Verification (UA Form #3) Completed
(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.)

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

Licensed Acupuncturist (L.Ac.)

Licensed Acupuncturist (L.Ac.)

Occupational Therapist (O.T.)

Occupational Therapist (O.T.)

Occupational Therapy Assistant (O.T.A.)

Occupational Therapy Assistant (O.T.A.)

Physician Assistant (P.A.)

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 of 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

Physical Therapist (P.T.)

Physical Therapist (P.T.)

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.)
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 of 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
PT Jurisprudence Exam

Physical Therapist Assistant (P.T.A.)

Physical Therapist Assistant (P.T.A.)

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.)
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 of 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

Radiologic Technologist (L.R.T.)

Radiologic Technologist (L.R.T.)

Respiratory Therapist (R.T.)

Respiratory Therapist (R.T.)

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