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Forms for Licensees


Primary Source Verification Letter  

This is an official letter confirming that our website www.bmp.state.mn.us is a primary source for verification of license credentials consistent with the Joint Commission and National Committee for Quality Assurance (NCQA) standards.  This letter is used by credentialing verification organizations to comply with credentialing standards of the Joint Commission and NCQA 

Name Change Form

Submit this form with a notarized copy of the marriage certificate, divorce or dissolution of marriage, or other court order. The notarization must be the original notarization. The Board cannot accept copies of a previously notarized document, faxes, or emails. The notary will sign/stamp/seal the photocopy and write a statement that they have viewed the original and this is an exact copy. Some notaries may attach a paper with a similar statement to the copy.

License Card or Wall Certificate Replacement Request

Request for replacement of annual license card or wall certificate.  All replacement documents will be marked "Duplicate".


Athletic Trainers

Athletic Trainer Protocol - This protocol form must be updated and reviewed at the athletic trainer’s renewal time and kept on file by the athletic trainer.  It is recommended that the primary physician also retain a copy.  Do not submit to the Board unless requested.

Physicians

Dispensing Drugs for Profit – Statement must be filed if dispensing drugs for profit.  This law refers only to drugs that are:  1) to be administered orally; 2) ordinarily dispensed by pharmacists; and 3) not vaccines.

Physician Assistants

Add/Delete Alternate Supervisors – PAs are no longer required to provide written notification to the board re:  the addition or deletion of alternate supervising physicians.  This form is provided as a service by the Board to facilitate the process to add or delete alternate supervising physicians in practice records.

Delegation Agreement (formerly Supervisory Agreement) – The Delegation Agreement must be kept on file at the practice site and reviewed at least annually at PA license renewal time. Do not submit to the Board unless requested.

Dispensing Drugs for Profit - Statement must be filed if dispensing drugs for profit.  This law refers only to drugs that are:  1) to be administered orally; 2) ordinarily dispensed by pharmacists; and 3) not vaccines.

Notice of Intent to Practice (formerly Practice Setting Description) – This form must be completed and submitted to the Board prior to beginning practice as a PA.  A new Notice must be submitted to the Board when there is a change in primary supervising physician or place of employment.