ALLIED HEALTH RNWL REQUEST 2024 NEW
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES ----------------0--------------- DEPARTMENT OF HEALTH “Wellness is Our Way of Life” P.O. BOX 222995 CHRISTIANSTED, VI 00822-2995 PROFESSIONAL LICENSURE & HEALTH PLANNING Tel. (340) 643-8992 Plhpdocuments@doh.vi.gov Allied Health Renewal Request (FILLABLE FORM - PLEASE TYPE ONLY) DATE: ______________ NAME: _____________________________ ___________________ _______________________ _________ first middle last suffix MAILING ADDRESS: _____________________________________________CITY__________________STATE____ZIP CODE__________ RESIDENTIAL ADDRESS:___________________________________________CITY___________________STATE____ZIP CODE__________ EMAIL ADDRESS: _____________________________________________ MOBILE PHONE NUMBER: _________________________ WORK PHONE NUMBER: _________________________ OCCUPATION:________________________________________________ DCLA CONTROL# ___________________ BUSINESS NAME:___________________________________________________________________________ PHYSICAL BUSINESS ADDRESS: ____________________________________CITY …
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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES ----------------0--------------- DEPARTMENT OF HEALTH “Wellness is Our Way of Life” P.O. BOX 222995 CHRISTIANSTED, VI 00822-2995 PROFESSIONAL LICENSURE & HEALTH PLANNING Tel. (340) 643-8992 Plhpdocuments@doh.vi.gov Allied Health Renewal Request (FILLABLE FORM - PLEASE TYPE ONLY) DATE: ______________ NAME: _____________________________ ___________________ _______________________ _________ first middle last suffix MAILING ADDRESS: _____________________________________________CITY__________________STATE____ZIP CODE__________ RESIDENTIAL ADDRESS:___________________________________________CITY___________________STATE____ZIP CODE__________ EMAIL ADDRESS: _____________________________________________ MOBILE PHONE NUMBER: _________________________ WORK PHONE NUMBER: _________________________ OCCUPATION:________________________________________________ DCLA CONTROL# ___________________ BUSINESS NAME:___________________________________________________________________________ PHYSICAL BUSINESS ADDRESS: ____________________________________CITY____________________STATE____ZIP CODE_________ DCLA LICENSE#:________________________________________________ EXPIRATION DATE: ___________________ Updated January 29, 2024. Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 643-8992 Failure to furnish all required documents will delay processing. APPLICANT NAME:_______________________________________ PLEASE BE SURE TO ATTACH COPIES OF THE FOLLOWING: (INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED) 1. ❑ EIGHT (10) CONTINUING EDUCATION CREDITS ANNUALLY; 2. ❑ UPDATED PROFESSIONAL CREDENTIALS; 3. ❑ UPDATED CERTIFICATIONS AND/OR STATE LICENSES; 4. ❑ PROOF OF ATTENDANCE TO A 3 HOUR HIV/STD COURSE; AND 5. ❑ PROOF OF MALPRACTICE INSURANCE. 6. ❑ SUBMIT A CURRENT (DATED WITHIN 6 MONTHS OF VI APPLICATION) NATIONAL PRACTITIONER DATA BANK SELF-QUERY. A. VISIT HTTPS://WWW.NPDB.HRSA.GOV/EXT/SELFQUERY/SQHOME.JSP AND BEGIN THE PROCESS FOR THE SELF-QUERY. FOLLOW ALL INSTRUCTIONS GIVEN. B. AFTER YOUR SELF-QUERY HAS BEEN PROCESSED BY THE NPDB, THEY WILL SEND THE SELF-QUERY REPORT DIRECTLY TO YOU. C. YOU MUST FIRST OPEN THIS REPORT TO MAKE SURE THAT THE RESULTS WERE NOT REJECTED, AND ALL INFORMATION SUBMITTED IS CORRECT. D. SEND ALL PARTS OF THE SELF-QUERY REPORT DIRECTLY TO OUR OFFICE WITH YOUR APPLICATION. E. FOR NPDB QUESTIONS OR ASSISTANCE, CALL 800-767-6732 OR EMAIL HELP@NPDB.HRSA.GOV. 7. ❑ PLEASE EMAIL YOUR COMPLETED RENEWAL FORM AND DOCUMENTS TO PLHPDOCUMENTS@DOH.VI.GOV.