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WV Board of Medicine Search
Licensee Forms
BOARD FORMS
The following forms are available online and may be printed, completed, and mailed to the Board offices. Please click on the file below for available forms. All forms may be reviewed and printed with Adobe Acrobat Reader 6.0 or higher.
Related Information
Forms & Documents
- Charitable Licensure Exemption Authorization (191 kb PDF)
- Medical Professional Liability Claim Report - Insurer (564 kb PDF)
- Medical Professional Liability Claim Report - Practitioner (77 kb PDF)
- Name Change Affidavit (53 kb PDF)
- MD Duplicate Wall License Request Form (11 kb PDF)
- Duplicate Wallet Card Request Form (77 kb PDF)
- Military Deployment Application Waiver Request (205 kb PDF)
- Military Deployment Application Continuation of License (205 kb PDF)
- Military Deployment Application Spouse Waiver Request (205 kb PDF)
Licensure
The West Virginia Board of Medicine is the sole authority for the issuance of licenses to practice medicine and surgery, to practice podiatry, and to practice as a physician assistant in collaboration with MDs and DPMs in the State of West Virginia, and is the regulatory and disciplinary body for medical doctors, podiatric physicians and their physician assistants.
Contact Us
101 Dee Drive
Suite 103
Charleston WV 25311
Phone: (304) 558-2921
Fax: (304) 558-2084
Map: Contact Page
Hours: 8:30 AM - 4:30 PM EST
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