Forms and Applications

Act 125/Envision School Health Program

• Certificate of Achievement
• Envision Program enrollment form

Act 125/Envision home page

Asbestos and Lead Program

• Essential Maintenance Practices Affidavit of Performance (pdf)
• Contractor Entity Application Form (pdf)
• Asbestos Contractor Individual Application Form (pdf)
• Asbestos Abatement Project Permit Application Form (pdf)
• NESHAP Notification (pdf)
• NESHAP form general instructions (pdf)
• Lead Abatement Contractor Entity Application Form (pdf)
• Lead Abatement Contractor Individual Application Form (pdf)
• Lead Abatement Project Permit Application Form (pdf)

Asbestos and Lead Program home page

Birth, Death, Civil Union, Marriage Certificate Order Forms

The Health Department keeps the most recent five years of records. After five years, records are transferred to Public Records, the State Archive. Please go to the Public Records site to order certificates that are older than five years.

• How to obtain a certificate from the Health Department
• Order certificates from Public Records

Vital Records home page

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Board of Medical Practice

• Board of Medical Practice home page

Fees (Current and Furture)

• Current and Future Fee Schedule

Physician

• Initial License Application for Physicians
  • License Renewal Application for Physicians
  • License Reinstatement Application for Physicians
• Initial Application for Limited Temporary Physician License
  • Renewal Application for Limited Temporary Physician Licensee

Podiatrist

• Initial Application for Podiatrists
  • Renewal Application for Podiatrists
  • Reinstatement Application for Podiatrists

Physician Assistant

• Initial License Application for Physician Assistants
  • Application for Secondary Certification as a Physician's Assistant
  • Renewal application for Physician Assistants
  • Notification to the Board of Termination of Employment Contract

Anesthesiologist Assistant

• Initial Application for Anesthesiologist Assistant Certification
  • Anesthesiologist Assistant renewal

Other Medical Board forms

• Complaint form

Prescriber Data-Sharing Program

• Consent Form
• Revocation of Consent Form
• Fact Sheet for Prescribers
• Frequently Asked Questions

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Emergency Medical Services

• Students and recertifying EMS providers
• EMS course and exam coordinators
• Applications for reciprocity
• Service managers/administrators

EMS home page

Food and Lodging Program

• Application for License to Operate a Food & Lodging Establishment(pdf)

Food and Lodging Program home page

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Immunization Registry Program

• Confidentiality Agreement form

Immunization Registry Program

HIV/AIDS Medication Assistance Program, Dental Care Assistance Program

• HIV/AIDS Assistance Programs Application and Instructions (pdf)
• Physician Verification of HIV Status form (pdf)
• Release of Information Form (pdf)

HIV/AIDS home page

Ladies First

Forms for providers

• Ladies First/EDS Provider Enrollment Form (pdf )
• Authorization for Electronic Funds Transfer (pdf)
• EDI Registration (pdf)
• Electronic Data Interchange Trading Partner Agreement (pdf)

Ladies First home page

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Mental Health

• Adult mental health forms
• Children's mental health forms
• State hospital forms

Mental Health home page

Public Health Laboratory

• Water test order form (pdf)
• Inorganic chemicals supplement (pdf)

Public Health Laboratory home page

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Radiological Health

• Registration of X-Ray Equipment/Sources of Ionizing Radiation (pdf)

Radiological Health home page

WIC: Women, Infant and Children Program

• Enrollment form (pdf)
• Completing the Proof of Delivery form

WIC home page

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