Licensure Forms

The forms on this page were created using Adobe Acrobat. They are best viewed with that software or Acrobat Reader. If your browser does not support this feature, please save the document to your local computer and then open it directly in one of the Acrobat applications. Adobe Acrobat Reader is available at no charge from Adobe (click the Get Adobe Acrobat Reader link below to download the software):

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.

• Sports Waiver (S.W.)
• 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.)

Sports Waiver (S.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.)

  • 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
  • Athletic Trainer Federal Enclave Practice Protocol 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)
  • Renewal Application
  • Third Party Release Form (Fillable PDF)

  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

    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