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 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.
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 Assistant Collaborative Practice Instruction and Affidavit Form
(For new PA applicants who submit the application after August 1, 2020.)
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.
New applicants and exiting licensees don't need to submit Delegation Agreement and Practice Location Notification to the Board after August 1, 2020.