Licensure Certification Form - Medical Quality Assurance

COMPLETE, PRINT AND ATTACH $25 PROCESSING FEE FOR EACH REQUEST (Make check or money order payable to the appropriate licensing board.) If you are requesting that your exam scores be submitted with your request for certification, please complete and forward the attached form with your request for certification. Please be aware that most states do not require exam scores, please check with the licensing authority prior to requesting this information. Waiver of Confidentiality and Authorization to Release Scores Form
Return form and fee to:	Division of Medical Quality Assurance Licensure Support Services Attn: License Verifications P.O. Box 6320 Tallahassee, FL 32314-6320

LICENSURE CERTIFICATION FORM
Items to be Researched:
Name:
License Number:
Profession:
Certification to be sent to:
Name or State
Mailing address
City/State/Zip Code
Telephone number:	Area Code:	Number:
Special instructions to processor (limit to five lines):
If you wish to have the certification faxed or emailed, include your fax number and/or email address.
FAX Number:	Area Code:	Number:
Email Address: