18VAC85-20 Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic

REGULATIONS

Vol. 28 Iss. 10 - January 16, 2012

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF MEDICINE

Chapter 20

Forms

REGISTRAR'S NOTICE: The following forms used in administering the regulations referenced below have been filed by the Board of Medicine. Amended or added forms are not being published, but online users of the Virginia Register of Regulations may view the forms by clicking on the title of the form. The forms are also available through the agency contact listed below or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

Titles of Regulations: 18VAC85-20. Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic.

18VAC85-40. Regulations Governing the Practice of Respiratory Care Practitioners.

18VAC85-50. Regulations Governing the Practice of Physician Assistants.

18VAC85-80. Regulations Governing the Licensure of Occupational Therapists.

18VAC85-110. Regulations Governing the Practice of Licensed Acupuncturists.

18VAC85-120. Regulations Governing the Licensure of Athletic Trainers.

18VAC85-130. Regulations Governing the Practice of Licensed Midwives.

Agency Contact: Elaine J. Yeatts, Senior Policy Analyst, Virginia Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone [phone], FAX [phone], or email [e-mail].

FORMS (18VAC85-20)

Instructions for Completing an Application to Practice Medicine in Virginia for Graduates of Approved Medical Schools in the US/Canada (rev. 7/08).

Instructions for Completing an Application to Practice Medicine for Graduates of Nonapproved Medical Schools (outside of the US/Canada) (rev. 7/08).

Information for Completing Chiropractic Endorsement Application (rev. 8/07).

Instructions for Completing Podiatry Endorsement Application (rev. 8/07).

Instructions for Completing Osteopathic Medicine Licensure Application (rev. 11/07).

Instructions and Application for a License to Practice Medicine and Surgery in Virginia for Graduates of American Medical Schools (US/Canada) (rev. 3/10).

Instructions and Application for a License to Practice Medicine and Surgery for Graduates of Non-American Medical Schools (outside of the US/Canada) (rev. 3/10).

Information and Chiropractic Endorsement Application (rev. 12/08).

Information and Podiatry Endorsement Application (rev. 12/08).

Instructions and Application for a License to Practice Osteopathic Medicine (rev. 1/09).

Form A, Claims History Sheet (rev. 8/07).

Form B, Activity Questionnaire (rev. 8/07).

Form C, Clearance from Other State Boards (rev. 8/07).

Form E, Disciplinary Inquiry (rev. 8/07).

Application for a License to Practice Medicine and Surgery (rev. 11/07).

Application for a License to Practice Osteopathic Medicine (rev. 11/07).

Application for a License to Practice Podiatry (rev. 8/07).

Application for a License to Practice Chiropractic (rev. 8/07).

Form H, Federation of Podiatric Medical Boards Report (rev. 8/07).

Requirements and Instructions for an Intern/Resident License (rev. 8/07).

Intern/Resident, Form A, Memorandum from Associate Dean of Graduate Medical Education (rev. 8/07).

Intern/Resident, Form B, Certificate of Professional Education (rev. 8/07).

Application for a Temporary License for Intern/Resident Training Program (rev. 8/07).

Form B, Activity Questionnaire (rev. 10/09).

Form C, Clearance from Other State Boards (rev. 11/09).

Form E, Disciplinary Inquiry (rev. 5/11).

Form H, Federation of Podiatric Medical Boards Report (rev. 12/08).

Instructions and Application for a Temporary License for Intern/Resident Training Program (rev. 8/07).

Form A, Intern/Resident, Memorandum from Associate Dean of Graduate Medical Education (rev. 8/07).

Form B, Intern/Resident, Certificate of Professional Education (rev. 8/07).

Form G, Intern Resident, Request for Status Report of ECFMG Certification (eff. 8/07).

Form H, Report of Clinical Rotations (rev. 12/02).

Transfer Request, Intern/Resident (eff. 8/07).

Instructions for Completing an Application for a Limited License to Foreign Medical Graduates Pursuant to 54.1-2936 (rev. 8/07).

Application for a Limited License to Foreign Medical Graduates Pursuant to 54.1-2936 (rev. 8/07).

Form G, Request for Status Report of Educational Commission for Foreign Medical Graduates Certification (rev. 8/07).

Form L, Certificate of Professional Education (rev. 8/07).

Form L, Certificate of Professional Education (rev. 12/08).

Continued Competency Activity and Assessment Form (rev. 9/07).

Instructions for Reinstatement of Medicine and Surgery Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Medicine (rev. 8/07).

Form A, MD Reinstatement, Claims History Sheet (rev. 8/07).

Application for Reinstatement of License to Practice Medicine (rev. 3/09).

Form A, MD Reinstatement, Claims History Sheet (rev. 9/09).

Form B, MD Reinstatement, Activity Questionnaire Form (rev. 8/07).

Form C, MD Reinstatement, State Questionnaire Form (rev. 8/07).

MD Reinstatement, Disciplinary Inquiries to Federation of State Medical Boards (rev. 8/07).

Instructions for Reinstatement of Osteopathic Medicine Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Osteopathic Medicine (rev. 8/07).

Form A, Osteopathy Reinstatement, Claims History (rev. 8/07).

Instructions for Reinstatement of a Chiropractic Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice as a Chiropractor (rev. 8/07).

Instructions for Reinstatement of Podiatry Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Podiatry (rev. 8/07).

Reinstatement Application Instructions for Medicine & Surgery or Osteopathy Licensure after Reinstatement Denied or License Revoked (rev. 8/07).

Reinstatement Application Instructions for Medicine & Surgery or Osteopathy Licensure after Mandatory Suspension, Suspension or Surrender (rev. 8/07).

Reinstatement Application Instructions for Podiatry Licensure after Mandatory Suspension, Suspension or Surrender (rev. 8/07).

Application for Reinstatement of License to Practice Medicine/Osteopathy After Petition for Reinstatement Denied or License Revoked (rev. 8/07).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

Guidelines for Completing the Practitioner Profile Questionnaire (rev. 12/02).

Practitioner's Help Section (rev. 11/07).

Practitioner Questionnaire (rev. 8/04).

Guidelines for Completing the Practitioner Profile Questionnaire (rev. 7/11).

Practitioner's Help Section (rev. 11/10).

Practitioner Questionnaire (rev. 7/11).

FORMS (18VAC85-40)

Instructions for Completing a Respiratory Care Practitioner Application (rev. 12/07).

Application for a License to Practice as a Respiratory Care Practitioner (rev. 12/07).

Instructions for Completing Reinstatement Application for Respiratory Care Practitioner License (rev. 8/07).

Application for Reinstatement of License to Practice Respiratory Care (rev. 10/07).

Instructions and Application for Reinstatement of License to Practice Respiratory Care (rev. 11/10).

Instructions (rev. 1/09) and Application for a License to Practice as a Respiratory Care Practitioner (rev. 12/07).

Reinstatement Application Instructions for Respiratory Care Practitioner after Reinstatement Denied or License Revoked (rev. 8/07).

Reinstatement Application Instructions for Respiratory Care Practitioner after Mandatory Suspension, Suspension or Surrender (rev. 8/07).

Form A, Claims History Sheet (rev. 8/07).

Form B, Activity Questionnaire (rev. 8/07).

Form C, Clearance from Other State Boards (rev. 8/07).

Form L, Certificate of Professional Education (rev. 8/07).

Verification of Certification Request Form (NBRC) (rev. 8/07).

Form L, Certificate of Professional Education (rev. 1/09).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

FORMS (18VAC85-50)

Instructions for Completing a Physician Assistant Licensure Application (rev. 2/08).

Application for Licensure as a Physician Assistant (rev. 8/07).

Instructions and Physician Assistant Licensure Application (rev. 10/09).

Form #B, Activity Questionnaire (rev. 8/07).

Form #C, Clearance from Other State Boards (rev. 8/07).

Form #L, Certificate of Physician Assistant Education (rev. 8/07).

Form #L, Certificate of Physician Assistant Education (rev. 10/09).

Form #2, Physician Assistant Invasive Procedures Protocol (rev. 8/07).

Instructions for Completing a Practice Application as a Physician Assistant (rev. 11/07).

Application for Practice as a Physician Assistant (rev. 11/07).

Request for Prescriptive Authority from the PA (rev. 8/07).

Alternate Supervisors Signature Form (rev. 3/03).

Instructions and Practice Application as a Physician Assistant (rev. 10/09).

Request for Prescriptive Authority from the PA (rev. 1/11).

Alternate Supervisors Signature Form (rev. 2/09).

Form #1-A, Addendum to Practice of Physician Assistant Duties (rev. 8/07).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

Physician Assistant Volunteer License Application (eff. 3/03).

Physician Assistant Volunteer License Application (rev. 12/07).

FORMS (18VAC85-80)

Instructions for Completing an Occupational Therapist Licensure Application (rev. 12/07).

Application for a License to Practice as an Occupational Therapist (rev. 12/07).

Instructions for Completing an Occupational Therapy Assistant Licensure Application (eff. 11/08).

Application for a License to Practice as an Occupational Therapy Assistant (eff. 11/08).

Instructions and Application for Occupational Therapist Licensure (rev. 1/09).

Instructions and Application for Occupational Therapy Assistant Licensure (rev. 1/09).

Form A, Claims History Sheet (rev. 8/07).

Form A, Occupational Therapy Assistant, Claims History Sheet (eff. 11/08).

Form B, Activity Questionnaire (rev. 8/07).

Form B, Occupational Therapy Assistant, Activity Questionnaire (eff. 11/08).

Form C, Clearance from Other State Boards (rev. 10/07).

Form C, Occupational Therapy Assistant, Clearance from Other State Boards (eff. 11/08).

Form L, Certificate of Professional Education (rev. 8/07).

Form L, Occupational Therapy Assistant, Certificate of Professional Education (eff. 11/08).

Form L, Occupational Therapy, Certificate of Professional Education (rev. 1/09).

Form L, Occupational Therapy Assistant, Certificate of Professional Education (rev. 1/09).

Board Approved Practice, Occupational Therapist Traineeship (rev. 8/07).

Instructions for Completing Reinstatement of Occupational Therapy Licensure (rev. 8/07).

Instructions and Application for Reinstatement of Occupational Therapy Licensure (rev. 11/10).

Reinstatement Application Instructions for Occupational Therapy Practitioner Licensure after Mandatory Suspension, Suspension or Surrender (rev. 10/07).

Application for Reinstatement of Licensure to Practice Occupational Therapy (rev. 8/07).

Instructions for Supervised Practice, Occupational Therapy Reinstatement (rev. 8/07).

Supervised Practice Application, Occupational Therapy Reinstatement (rev. 8/07).

Continued Competency Activity and Assessment Form (rev. 4/00).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

FORMS (18VAC85-110)

Instructions for Completing an Application for a License to Practice as an Acupuncturist - Graduates of Approved Institutions or Programs in the United States (rev. 8/07).

Instructions for Completing an Application for a License to Practice as an Acupuncturist - Graduates of Nonapproved Educational Programs (rev. 8/07).

Application for a License to Practice as an Acupuncturist (rev. 8/07).

Form A, Claims History Sheet (rev. 8/07).

Form B, Activity Questionnaire (rev. 8/07).

Form C, Clearance from Other State Boards (rev. 8/07).

Form L, Certification of Professional Education (rev. 8/07).

Instructions and Application for a License to Practice as an Acupuncturist - Graduates of Approved Institutions or Programs in the United States (rev. 11/10).

Instructions and Application for a License to Practice as an Acupuncturist - Graduates of Nonapproved Educational Programs (rev. 11/10).

Form A, Claims History Sheet (rev. 11/10).

Form B, Activity Questionnaire (rev. 11/10).

Form C, Clearance from Other State Boards (rev. 11/10).

Form L, Certification of Professional Education (rev. 11/10).

Verification of NCCAOM Certification (rev. 3/08).

Recommendation for Examination by a Physician (rev. 11/06).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

Instructions for Completing a Reinstatement Application for Licensed Acupuncturist (rev. 8/07).

Reinstatement Application Instructions for Licensed Acupuncturist after Suspension, Surrender or Mandatory Suspension (rev. 8/07).

Application for Reinstatement of a License to Practice as a Licensed Acupuncturist (rev. 8/07).

Instructions and Application for Reinstatement as a Licensed Acupuncturist (rev. 2/09).

Instructions for Completing a Reinstatement Application for Licensed Acupuncturist after Suspension, Surrender, or Mandatory Suspension (rev. 3/10).

Application for Reinstatement of a License to Practice as a Licensed Acupuncturist after Suspension, Surrender, or Mandatory Suspension (rev. 3/10).

FORMS (18VAC85-120)

Instructions for Completing an Athletic Trainer Licensure Application (rev. 12/07).

Application for a License to Practice as an Athletic Trainer (rev. 12/07).

Instructions for Completing and Athletic Trainer Licensure Application (10/09).

Form A, Claims History (rev. 8/07).

Form B, Activity Questionnaire (rev. 8/07).

Form C, Clearance from Other State Boards (rev. 8/07).

Form L, Certificate of Professional Education (rev. 8/07).

Provisional License to Practice as an Athletic Trainer Pursuant to 18VAC85-120-80 (rev. 8/07).

Provisional License to Practice as an Athletic Trainer Pursuant to 18VAC85-120-80 (rev. 10/10).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

Instructions for Completing a Reinstatement Application for Athletic Training (rev. 8/07).

Application for Reinstatement of a License to Practice as an Athletic Trainer (rev. 8/07).

Instructions for Completing and a Reinstatement Application for Athletic Training (rev. 11/10).

FORMS (18VAC85-130)

Instructions for Completing a Licensed Midwife Application (rev. 12/07).

Application for a License to Practice as a Licensed Midwife (rev. 12/07).

Form A, Claims History (rev. 8/07).

Form B (rev. 8/07).

Form C (rev. 8/07).

Instructions for and Application to Practice as a Licensed Midwife (rev. 11/10).

Form A, Claims History (rev. 11/10).

Form B, Activity Questionnaire (rev. 11/10).

Form C, Jursidiction Clearance (rev. 11/10).

VA.R. Doc. No. R12-2953; Filed December 16, 2011, 11:35 a.m.