Applications and Other Forms

BOARD OF MEDICINE

Applications & Other Forms

Uniform Application (UA) for physicians. The UA is designed to make the physician licensing process more portable among states, convenient and less redundant.

Addendums, Affidavit, and Authorization for Release of Information

REVISED PA PRACTICE CHANGE FORMS NOTICE

Supervising Physician Forms

All packets include a Supervising Physician Registration Form

Supervising Physician Registration Form & PA Delegation of Services Agreement Forms

Please Note: Physician assistants are required to have a Board-approved supervising physician prior to practice and complete or maintain a current copy of the Board-approved delegation of services agreement as specified by Section 30. Failure to do so is grounds for disciplinary action.

Medical Resident Supervisor Form

Cosmetic & Laser Medical Personnel Packet & Rules (NOT to be used for PA Supervision)

Directing Physician Forms

Directing Physician Registration Form & AT Service Plan or Protocol Forms

Medical Resident Forms

Medical Resident Application

PLEASE NOTE: Physicians supervising Nurse Practitioners are not required to register with the Board of Medicine.

Licensing Specialists

Physician Licensure

(A-L) Linda Holt linda.holt@bom.idaho.gov

(M-Z) Sai Ellis sai.ellis@bom.idaho.gov