Verification Request Form (Multiple) 2024 (R)
Name License Type License No. Qty. Subtotal Total Quantity & Amount Due: Verifications 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 per provider. Note: Beginning October 1, 2024 all verifications will be $35.00 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 Dept. of Health-STX P.O. Box 222995 Christiansted, VI 00822-2995 (340) 643-8992 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, …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://doh.vi.gov/wp-content/uploads/2024/03/Verification-Request-Form-Multiple-2024-R.pdf
SHA-256 64f7ce331b2c6826f00600260d57e1ea3b640325bf71b1b9154c931487b4bfd2
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-64f7ce331b2c
Document text
Name License Type License No. Qty. Subtotal Total Quantity & Amount Due: Verifications 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 per provider. Note: Beginning October 1, 2024 all verifications will be $35.00 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 Dept. of Health-STX P.O. Box 222995 Christiansted, VI 00822-2995 (340) 643-8992 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