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Physician - Application Forms

Application for Endorsement by Exam, Re-Registration, and Visiting Professor 
Form # Title/Description
570  Application to Practice Medicine and Surgery
571  Authorization and Waiver 
2165  Certification of Post Graduate Training Not necessary if utilizing FCVS.
2252  Convictions and Pending Charges 
1445  Disciplinary Inquiries Report Not necessary if utilizing FCVS.
3046 Joint Commission Certified Hospital, Facility and Employer Verification Only for use by employment agencies to verify affiliation with multiple facilities. To verify a single facility, please use form 2167 below.
2167  Hospital, Facility and Employer Verification Form 
2829  Malpractice Suits or Claims Form 
2164  Medical Education Verification Form Not necessary if utilizing FCVS.
 
Application for Minnesota Licensees
Form # Title/Description
2862  Application For License to Practice Medicine and Surgery for Individuals with a Current Unrestricted Minnesota License You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
571  Authorization and Waiver 
2252  Convictions and Pending Charges
1445  Disciplinary Inquiry Report from the Federation of State Medical Boards 
2861  Information for completing Application for Individuals to Practice Medicine and Surgery with a Current Unrestricted Minnesota License 
2829  Malpractice Suits or Claims Form If applicable.
 
Application for Temporary Camp Physician or Locum Tenens
Form # Title/Description
568  Application for Temporary Camp Physician or Locum Tenens License  
You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
2252  Convictions and Pending Charges 
1445  Disciplinary Inquiries Report  Not necessary if utilizing FCVS.
2829  Malpractice Suits or Claims Form 
 
Application for Temporary Education Permit
Form # Title/Description
2601  Affidavit of Hospital Authority 
3050 Temporary Education Permit Certificate of Professional  Education Form This form must be returned directly from your school.
2329  Application for Renewal of Temporary Educational Permit 
564  Application For Temporary Educational Permit 
2252  Convictions and Pending Charges 
 

Other Information/Forms

Physician- License Information