Medical Quality Assurance (MQA) Services

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
OR
*Business/Company Name:   
*Please Select Request Type:
*Licensee Number:  Enter License Number with no spaces or leading zeroes.
*Profession: 
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
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
*State
*Postal Zip Code
Please enter any special instructions for the processor.