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Medical Quality Assurance 

LICENSURE CERTIFICATION FORM

COMPLETE, PRINT AND
ATTACH $25 PROCESSING FEE FOR EACH REQUEST
(Make check or money order payable to the appropriate licensing board.)
Return form and fee to: Division of Medical Quality Assurance
Client Services Unit - HMQAMS
Post Office 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: