Department of Health
Florida Health Source
License Certification Request Form:
Do Not Use This Form For License Renewal
Please use this form to request certification of your Florida license.
Please allow 7 to 10 days for your request to be processed.
If you need to verify a license that you hold in another state, please contact your state board.
If you are applying for a Florida license, you do not need to submit a verification request for your Florida license.
If you are requesting that your exam scores be submitted with your request for certification, please complete and forward the attached form with your request for certification. Please be aware that most states do not require exam scores, please check with the licensing authority prior to requesting this information.
Waiver of Confidentiality and Authorization to Release Scores Form
If you are trying to renew your license,
click here.
*Items below marked with an asterisk are required.
1 - Licensee to be Researched:
Please enter information here about the Person or Business whose License Certification you are requesting.
*Last/Surname:
*First Name:
Mid Initial:
Suffix:
Title
--Select--
Dr.
Mr.
Mrs.
Ms.
OR
*Business/Company Name:
*Please Select Request Type:
-- Select --
Certification
Non-Certification
*Licensee Number:
Enter License Number with no spaces or leading zeroes.
*Profession:
Select Profession
Acupuncturist
Advanced Practice Registered Nurse
Anesthesiologist Assistants
Apprentice Optician
Athletic Trainer
Audiologist
Audiology Assistant
Certified Chiropractic Physician's Assistant
Certified Master Social Worker
Certified Nursing Assistant
Certified Pod X-Ray Assistant
Certified Respiratory Therapist
Chiropractic Faculty Certificate
Chiropractic Physician
Clinical Laboratory Personnel
Consultant Pharmacist
Dental
Dental Hygienist
Dental Laboratory
Dental-Health Access Dental
Diagnostic Radiological Physicist
Dietetics/Nutritionist
Electrologist
Hearing Aid Specialist
Hearing Aid Specialist Trainee
Licensed Clinical Social Worker
Licensed Marriage and Family Therapist
Licensed Mental Health Counselor
Licensed Practical Nurse
Limited License Medical Doctor
Limited License Psychologist
Massage Establishment
Massage Therapist
Massage Therapy Apprentice
Medical Doctor
Medical Doctor Limited to Cleveland Clinic
Medical Doctor Limited to Mayo Clinic
Medical Doctor Public Health Certificate
Medical Doctor Public Psychiatry Certificate
Medical Doctor Restricted
Medical Doctor- Temporary Area of Critical Need
Medical Faculty Certificate
Medical Health Physicist
Medical Nuclear Radiological Physicist
Medical Physicist In Training
Midwifery
Naturopathic Physician
Nonresident Sterile Compounding
Nuclear Pharmacist
Nursing Education Program- PN
Nursing Education Program- RN
Nursing Home Administrator
Nutrition Counselor
Occupational Therapist
Occupational Therapy Assistant
Office Surgery Registration
Optical Establishment Permit
Optician
Optometric Faculty Certificate
Optometrist
Optometry Branch Office
Orthotic Fitter
Orthotic Fitter Assistant
Orthotist
Osteopathic Limited License
Osteopathic Physician
Osteopathic Resident Registration
Osteopathic- Temporary Area of Critical Need
Pain Management Clinic
Pedorthist
Pharmacist
Pharmacist Intern
Pharmacy
Physical Therapist
Physical Therapist Assistant
Physician Assistant
Podiatric Physician
Podiatric Resident Registration
Prosthetic Residents
Prosthetist
Prosthetist-Orthotist
Provisional Audiologist
Provisional Psychologist
Provisional Speech-Language Pathologist
Psychologist
Registered Chiropractic Assistant
Registered Clinical Social Worker Intern
Registered Marriage and Family Therapist Intern
Registered Mental Health Counselor Intern
Registered Nurse
Registered Pharmacy Technician
Registered Respiratory Therapist
Registration for Resident/HSE Physician
Respiratory Care Practitioner Critical Care
Respiratory Care Practitioner Non-Critical Care
Respiratory Care Practitioner by Exam
School Psychologist
Speech-Language Pathologist
Speech-Language Pathology Assistant
Temporary Midwife
Therapeutic Radiological Physicist
2 - Contact Information:
This information is needed if we need to contact you about this request. (Note: This is not the same as billing information.)
*Last/Surname:
*First Name:
Mid Initial:
Suffix:
Title
--Select--
Dr.
Mr.
Mrs.
Ms.
Email Address:
*Phone Number
-
-
Ext:
3 - Certification to be sent to:
Enter Basic
Mailing Data - This information will be used for mailing license certification.
Business/Company Name:
Attention:
Email address
*Phone Number
-
-
Ext:
Fax Phone Number
-
-
*Address Line 1
Address Line 2
*City
*Country
Select Country
AFGHANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTARCTICA
ANTIGUA & BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA & HERZEGOVINA
BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN
BRUNEI DARUSSALAM
BULGARIA
BURKINA FASO
BURMA
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REP
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS/KEELING ISL
COLOMBIA
COMOROS
CONGO
CONGO, DEM REP
COOK ISLANDS
COSTA RICA
COTE DIVOIRE
CROATIA/HRVATSKA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISL/MALVINA
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRANCE, METROPOLITAN
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH S TERRITORIES
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HEARD & MCDONALD ISL
HOLY,VATICAN CITY ST
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REP OF
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA, PEOPLES REP
KOREA, REP OF
KUWAIT
KYRGYZSTAN
LAO PEOPLES DEM REP
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAU
MACEDONIA,YUGOSLAV
MADAGASCAR
MALAWI
MALAYSIA
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MICRONESIA, FED ST
MOLDOVA, REP OF
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORKOLD ISLAND
NORTH KOREA
NORTHERN MARIANA ISL
NORWAY
OMAN
PAKISTAN
PALAU
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES
PITCAIRN
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
S GEORGIA SANDWICH
SAINT HELENA
SAINT LUCIA
SAMOA
SAN MARINO
SAO TOME & PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA & MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA/SLOVAK REP
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SPAIN
SRI LANKA
ST KITTS & NEVIS
ST PIERRE & MIQUELON
ST VINCENT & GRENADA
SUDAN
SURINAME
SVALBARD JAN MAYEN
SWAZILAND
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TAJIKISTAN
TANZANIA UNITED REP
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD & TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS ISL
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES
URUGUAY
US MINOR OUTLYING IS
UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
VIRGIN ISL -BRITISH
VIRGIN ISL -US
WALLIS & FUTUNA ISL
WEST BANK/GAZA STRIP
WEST INDIES
WESTERN SAHARA
YEMEN
YUGOSLAVIA
ZAIRE
ZAMBIA
ZIMBABWE
*State
Select State
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
AMERICAN SAMOA
F.S. OF MICRONESIA
GUAM
MARSHALL ISLANDS
MILITARY A
MILITARY E
MILITARY P
NORTH MARIANAS
PALAU
PRINCE EDWARD ISLAND
PUERTO RICO
VIRGIN ISLANDS
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEW FOUNDLAND
NOVA SCOTIA
NUNAVUT
NW TERRITORIES
ONTARIO
QUEBEC
SASKATCHEWAN
YUKON
OUT OF STATE
*Postal Zip Code
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