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It's a New Day in Public Health.

The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.

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NON-LICENSURE CERTIFICATION FORM

Contact the Florida Department of Health

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
Licensure Support Services
Post Office Box 6320
Tallahassee, FL 32314-6320

Items to be Researched:
Name:
License Number:
Profession:
Certification to be sent to:
Name or State:
Mailing address:
City/State/Zip Code:
Telephone 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.

(Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.)
FAX Number:
Email Address: