New Jersey Is an Equal Opportunity Employer. Printed on Recycled Paper and Recyclable
Certification in Support of Application for
Accelerated Temporary Healthcare Licensure by Reciprocity
I, _______________________________________________________, certify to the following:
Name
1) My home address is _______________________________________________________
2) My contact telephone numbers are ___________________________ (home)
___________________________ (work)
___________________________ (mobile).
3) My email address is _______________________________________________________
4) I hold a current license in good standing issued by the _______________________________
Board
of the state of ________________________________________, with license number
____________________________ and have practiced my profession within the last five years.
5) For MDs/DOs, Podiatrists, and Physician Assistants only: I have malpractice insurance. My malpractice
insurance carrier is ___________________________ and my policy number is
_____________________________
6) My area of practice specialty (if applicable) is ____________________________________
For informational purposes only:
7) I intend to treat patients ____ in person; ____ via telemedicine/telehealth (check all that apply)
8) I have the following specialized skills, training, or availability that are relevant during a public health
emergency:
_________________________________________________________________________
_________________________________________________________________________
By checking this box, I certify to truth and accuracy of the above: _____
Please send the completed document to NJTempLicense@dca.njoag.gov. Your application
will be reviewed and responded to within 24 hours.
PRACTITIONERS AUTHORIZED TO PRACTICE BY ACCELERATED TEMPORARY LICENSURE MUST COMPLY WITH ALL
APPLICABLE STATUTES AND RULES.
GO TO YOUR BOARD’S WEBSITE TO VIEW THESE DOCUMENTS.
Division of Consumer Affairs
Office of the Director
124 Halsey Street, 7
th
Floor, Newark NJ 07102-3017
GURBIR S. GREWAL
Attorney General
PAUL R. RODRIGUEZ
Acting Director
Mailing Address:
P.O. Box 45027
Newark, NJ 07101
(973)
504-6534
PHILIP D. MURPHY
Governor
S
HEILA Y. OLIVER
Lt. Governor
