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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 trainers 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

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.

Practice Location Notification (formerly Notice of Intent to Practice) This form must be completed and submitted to the Board within 30 business days of a qualifying event.

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