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Request for Wall Certification or Wallet ID Card
You must submit a copy of your
photo ID with your request in order to verify your identity to ensure your
information is released Only To You.
Physician Application for Licensure (Biennial)
(July 1, 2009 - June 30, 2011)
To apply for licensure as an Allopathic Physician (MD) in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Physician Application for Special Purpose Licensure
(Biennial)
(July 1, 2009 - June 30, 2011)
To apply for licensure as a Special Purpose Allopathic Physician (MD) in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Physician Application for Special Volunteer Medical
License
(2009-2011)
To apply for licensure as a Special
Volunteer Allopathic Physician (MD) in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Physician
Application for Special Event Medical License
(July 1, 2009 - June 30, 2011)
To apply for a Special
Event Medical License in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Physician Application for Status Change (2009-2011)
To apply for status change from inactive to active status as an
Allopathic Physician (MD) in the state of Nevada, download this printable form
(PDF File), which includes detailed instructions.
Physician Application for Licensure Reinstatement
(2009-2011)
To apply for reinstatement as a Physician Assistant in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Resident Application for Limited Medical License
(July 1, 2009 - June 30, 2010)
To apply for
licensure as an a Resident in the state of Nevada, download this printable form
(PDF File), which includes detailed instructions.
Physician Assistant Application for Licensure
(Biennial)
(July 1, 2009 - June 30, 2011)
To apply for licensure as a Physician Assistant in the state of Nevada, download
this printable form (PDF File), which includes detailed instructions.
Physician Assistant Application for Licensure
Reinstatement
(2009-2011)
To apply for reinstatement as a Physician Assistant in the state of Nevada,
download this printable form (PDF File), which includes detailed instructions.
Practitioner of Respiratory Care Application for Licensure (Mid-biennial)
(February 28, 2009 - February 28, 2010)
To apply for licensure as a Practitioner of Respiratory Care in the state of
Nevada, download this printable form (PDF File), which includes detailed
instructions.
Blood gas licenses are issued by the Bureau of Health Care Quality and
Compliance. You can contact that agency by calling 800-225-3414 (toll free) or
775-687-4475.
Practitioner of Respiratory Care Application for Licensure
Reinstatement
(2008-2010)
To apply for reinstatement as a Practitioner of Respiratory Care in the state of
Nevada, download this printable form (PDF File), which includes detailed
instructions.
Authorization for Criminal Background
Investigation
This form must be completed and submitted with an application for licensure as
an Allopathic Physician (MD). as a Physician Assistant, as a Practitioner of
Respiratory Care or as a Perfusionist in the state of Nevada. Download this
printable form (PDF File), complete, and submit the form with the application.
Notification of Supervision of Physician Assistant
To notify the Nevada State Board of Medical Examiners of supervision of a
Physician Assistant, download this printable form (PDF File).
Notification of Collaboration with Advanced
Practitioner of Nursing
To notify the Nevada State Board of Medical Examiners of collaboration with
an Advanced Practitioner of Nursing, download this printable form (PDF File).
Notification of Address Change
To notify the Nevada State Board of Medical Examiners of change of
practice address, download this printable form (PDF File), complete and mail
to the Nevada State Board of Medical Examiners at P.O. Box 7238, Reno, NV
89510-7238.
IN-OFFICE
SURGERY REPORTING FORMS FOR 2008
(The 2009 Forms will be Available
on or Before 12/3/09.)
In-Office
Surgery Reporting Form, Form A
To report in-office surgical procedures performed during the previous year
(2008), download this printable form (PDF File), to comply with annual reporting
requirements.
In-Office Surgery Sentinel Event Reporting Form
To report sentinel events included on Form A for reporting of in-office
surgical procedures performed during the previous year (2008), download this
printable
form (PDF File), to comply with annual reporting requirements.
In-Office Surgery Reporting Form, Form B
If you DID NOT perform any in-office surgical procedures during the previous
year (2008), download this printable form (PDF File) to comply with annual
reporting requirements.
In-Office Surgery Reporting Form Instructions
IMPORTANT: Please read before completing any In-Office Surgery Reporting Forms.
Download this printable set of instructions (PDF File).
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