Verification Request Form (Single) 2023 (R)
Licensee / Facility Name ________________________________ License Type __________________________ License Number ________________________ Verification will be emailed to: *Please attach authorization to request a license verification if you are not the license holder. Remit this form and $10.00 fee (7 calendar days processing time); $35.00 fee (48 hours processing time) per provider. Acceptable forms of payment are: credit card authorization form (below), certified check or money order, made payable to “GOV’T of the VI” to: Professional Licensure and Health Planning c/o VI Department of Health-STX P.O. Box 222995 Christiansted, VI 00822 (340) 773-1561 Ext. …
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Licensee / Facility Name ________________________________ License Type __________________________ License Number ________________________ Verification will be emailed to: *Please attach authorization to request a license verification if you are not the license holder. Remit this form and $10.00 fee (7 calendar days processing time); $35.00 fee (48 hours processing time) per provider. Acceptable forms of payment are: credit card authorization form (below), certified check or money order, made payable to “GOV’T of the VI” to: Professional Licensure and Health Planning c/o VI Department of Health-STX P.O. Box 222995 Christiansted, VI 00822 (340) 773-1561 Ext. 4431 plhpverify@doh.vi.gov LICENSE TYPES (DC) -Chiropractic (DDS, DMD) -Dentistry (RDH) -Dental Hygienist (MD, DO) -Medicine and Surgery (PA, PA-C) -Physician Assistant (PSY, PSYD, MA Psych Assoc.) -Psychologist (RPH, PharmD) -Pharmacist (CPTI, CPT, RPT, PPT) Pharmacy Technician (CTO, OD) -Optometry (PT, DPT) -Physical Therapy (PTA) -Physical Therapy Assistant (DPM) -Podiatry (DVM) -Veterinary Medicine (RVT)-Veterinary Technician (RRT) -Radiology Technician CON) -Certificate Need Pharmacy (ND, OT, MT) -Allied Health Clearance Letter Other: ___________________________________ Name Contact Person Agency Email Address OFFICE OF PROFESSIONAL LICENSURE AND HEALTH PLANNING P.O. Box 222995 CHRISTIANSTED, VI 00822-2995 License Verification / Good Standing Letter Request & Invoice Signature Date