Most of our forms are "pdf enhanced" so they can be filled out online. Select the "hand" tool from the Acrobat Reader tool bar. Move it to the first blank field or line and the hand will change to a cursor. Type your entry, then tab to the next space and type your information.
You must hit either the tab key or the enter key after typing in each blank on the form, or your entry won't be accepted and the information you typed won't print. To use check boxes, move the hand tool over the box and when hand becomes an arrow or finger, click once to mark box. Clicking again will remove mark. Print the form (click on the printer icon on the Adobe Acrobat Reader toolbar or use your Internet browser's print command), sign it, and mail it to the Board office.
- Address Change
- Application for Advanced Practice Approval - Hand Therapy
- Application for Advanced Practice Approval - Physical Agent Modalities
- Application for Advanced Practice Approval - Swallowing Assessment, Evaluation, or Intervention
- Application For Retired Status
- Application to Provide Advanced Practice Post-Professional Education
- Application To Restore Retired License
- Authorization for Release of Patient Health Information
- Authorization to Release Information
- CE Audit Evaluation Worksheet
- Customer Service Evaluation Form
- Declaration Statement Form
- Fieldwork Education PDU Attestation
- Name Change
- Name and Gender Change Notification and Request for Confidentiality (SB 372, 2023)
Effective January 1, 2024, under Business and Professions Code section 27.5, licensees may notify the licensing board or bureau within the Department of Consumer Affairs (DCA) of a name and/or gender change and request confidentiality of the previous name or gender information, when meeting certain specified requirements. For more information and to make a request, click here.
- PDU/Conviction Certification
- Probation - Quarterly Written Report (for Licensees on Probation)
- Probation - Work Performance Evaluation (for Supervisors)
- Report of Settlement, Judgment or Arbitration Award
- Request For Active Status
- Request for Pocket License/Wall Certificate