Florida

Board

of

Physical Therapy

Name changes require legal documentation showing the name change. To change your name, please submit supporting documents, which must be one of the following:

1. A copy of a state issued marriage license that includes the original signature and seal from the clerk of the court.
2. A divorce decree restoring your maiden name.
3. A court order showing the name change (adoption, legal name change, federal identity change).
4. A copy of a certificate of naturalization or H1B Employment Visa (Note: Foreign applicants and/or licensees may not have state issued documents)

Any one of these will be accepted unless the department has a question about the authenticity of the document.

The Division of Medical Quality Assurance is now issuing electronic licenses, which enables you to download a PDF copy of your license within two business days. The license can be retrieved in the License Documents menu of your MQA Online Services Portal account. To learn more, please visit the electronic licensing webpage at https://flhealthsource.gov/electronic-licensing/

For requests by mail, please include your full name as it appears on your license, profession, license number, your new name, your date of birth, the last four digits of your social security number, and your signature. Please submit your name change along with supporting document(s) 5-7 business days to allow processing if you need to renew online.

You may submit your request online or by mail along with legible supporting document(s) to one of the following:

•  Log onto your MQA Online Services Portal account , select “Request Name Change” from the “Manage My License” dropdown menu
• Mailing address – DOH, Division of Medical Quality Assurance, Post Office Box 6320, Tallahassee, Florida 32314-6320

UPDATE ADDRESS ONLINE:

• Login to online services by selecting your profession from the dropdown menu and entering your User ID and Password
• Your User ID and Password were mailed with your initial license. Please look at the center section and refer to the Online Services Instructions, item #5.
• If you do not have your User ID and Password, click on “Get Login Help“.
• Select “Update Addresses” on the left side of the page
• Enter the new address information
• Once you have entered your new address, click on “Process”. You will receive a confirmation page that displays the updated address.

About Your Practice Location Address

The practice location address will display on the Internet and your license. Your practice location must be a physical location address and must not include a Post Office box. The mailing address will only display on the Internet if you have not provided a practice location address to us. Establishment/Facility Name or Address If the name or address change is for a facility that has changed location, a licensure application must be submitted. See your profession’s web page for additional information.

UPDATE ADDRESS BY MAIL: If you prefer to change your address by mail, please complete the Change of Address form. Written requests for address changes must include your name, profession, license number, old address, new address, date of birth, last four digits of your social security number, and your signature.

PROCESSING TIME: If you are submitting an address change request by mail, please allow 5-7 business days for processing. Online requests will be processed within 48 hours.

The Division of Medical Quality Assurance is now issuing electronic licenses, which enables you to download a PDF copy of your license within two business days. The license can be retrieved in the License Documents menu of your MQA Online Services Portal, https://mqa-vo.doh.state.fl.us/datamart/voservicesportal account. To learn more, please visit the electronic licensing webpage at https://flhealthsource.gov/electronic-licensing/.

You may use our License Look-Up Search screen.

Any substantially affected person (i.e. a licensee or applicant) may seek a Declaratory Statement. Declaratory statements regarding an opinion of a board, or the department when there is no board, as to the applicability of a statutory provision, or of any rule or order of the board, or department when there is no board, as it applies to the licensees particular set of circumstances, pursuant to Section 120.565, Florida Statutes.

The petition seeking a declaratory statement must state with particularity the licensees set of circumstances and must specify the statutory provision, rule, or order that the licensee believes may apply to the set of circumstances.

Visit our Enforcement Website to download and complete our Unlicensed Activity Complaint Form. Before completing your complaint form, please be sure to review all instructions provided on the first page.

You may learn more about the Complaint process and submit the appropriate complaint forms by visiting our online Enforcement website.

You may visit our online License Verification page. You may utilize this service to see the status of your providers license and whether there are any disciplinary cases or public complaints against the licensee.

You can print a confirmation of license through the Practitioner Login feature of MQA Services. The confirmation is available up to 30 days after you submit your online renewal request.

After logging into the system with your User ID and password, select Print Confirmation of License from the navigation bar located on the left.

If you need a written statement on a public record attesting to the record’s genuineness or that it is a true and correct copy, you may fill out the Online Request Form.

Be sure to indicate you need a certified copy of the request form. A $25 fee will be charged, in addition to the public record Fees and Charges.

Visit our Public Records page for information on how to request certified documents by mail.

You may submit your request and payment online by visiting the Department’s License Certification webpage.

Make cashier’s check or money order payable to the Board/Council to be researched, in the amount of $25.00, for each verification requested.

• Include name and address where verification is to be sent
• Verification of Licensure order form
• Non-Licensure Verification order form Mail your request and fee to:

Division of Medical Quality Assurance
Licensure Support Services Attn: License Verifications
P.O. Box 6320 Tallahassee,
FL 32314-6320

Other Important Information:

• Requests for licensure verification received without the appropriate fee will be returned unprocessed to the sender.
• The Division of Medical Quality Assurance cannot guarantee your verification will meet the deadlines for other State Boards. The current processing time for licensure verifications is approximately 10 days from receipt. Please check your deadline dates before you submit your verification request.
• Release forms from the licensees are not required for verifications.

Exemptions: Financial information, medical information, school transcripts, examination questions, answers, papers, grades and grading keys, are confidential and exempt forms pursuant to Section 119.071, Florida Statutes, and will be withheld pursuant to Section 456.057, Florida Statutes. Social Security numbers will also be redacted pursuant to 42 U.S.C. 405(c)(2)(C) (vii)(1).

The Division of Medical Quality Assurance is now issuing electronic licenses, which enables you to download a PDF copy of your license within two business days. The license can be retrieved in the License Documents menu of your MQA Online Services Portal account. To learn more, please visit the electronic licensing webpage at https://flhealthsource.gov/electronic-licensing/.