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Physician License Verification Request Form - Massachusetts Board Of Registration In Medicine

Commonwealth of Massachusetts

Board of Registration in Medicine

200 Harvard Mill Square, Suite 330, Wakefield, MA 01880

Telephone (781) 876-8230

PHYSICIAN LICENSE VERIFICATION REQUEST

INSTRUCTIONS

REQUESTS FOR REVIEW OF COMPLAINT FILES MUST BE ACCOMPANIED BY A WAIVER

FORM PROVIDED BY THE BOARD OF REGISTRATION IN MEDICINE. NO OTHER FORMS

WILL BE ACCEPTED.

The attached Waiver for Release of Information form must be completed as directed and signed by the

physician requesting a License Verification, Certified Statement, or Letter of Good Standing (all are

considered the same form).

The fee for completing a License Verification, Certified Statement, or Letter of Good Standing is $10.00

(ten dollars) per verification request. (Full License verifications and Limited License verifications are

separate requests; the fee for each license verification is $10.00.)

Please make your check or money order payable to the Commonwealth of Massachusetts and forward

it to:

License Verification

Board of Registration in Medicine

200 Harvard Mill Square, Suite 330

Wakefield, MA 01880

License Verification requests will not be processed if the waiver form is substituted or incomplete,

or if the $10.00 processing fee for each license verification request is not included.

Please include a stamped envelope with the name and address of the recipient. If you wish to have the

verification sent via overnight delivery, please include a prepaid USPS envelope. We cannot send the

requests via UPS or FedEx.

Please allow at least three (3) weeks for processing of license verification requests.

NOTICE TO THE APPLICANT

THIS REQUEST IS BEING RETURNED FOR THE FOLLOWING REASON(S):

The Board’s waiver form is not included

The $10.00 fee has not been received and/or is incorrect

Physician License Verification Request Form - Massachusetts Board Of Registration In Medicine