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Licensing Forms
Sports Waiver (S.W.)
Sports Waiver (S.W.)
Telemedicine Waiver (T.W.)
Telemedicine Waiver (T.W.)
Athletic Trainer (A.T.)
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)
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.)
- (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.)
- 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.)
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.)
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.)
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.)
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.)
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 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
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)
- 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
- 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
- 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
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
- 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.)
- 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.)
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
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