Fillable HEALT H LICENSE VERIFICATION REQUEST Bureau of Professional (Michigan)

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HEALT H LICENSE VERIFICATION REQUEST Bureau of Professional (Michigan)

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LARA/BPL-DLVR-Health (Rev. 10/19)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex,
religion, age, national origin, color, marital
status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to
this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
HEALT
H LICENSE VERIFICATION REQUEST
Requestor’s First Name
Middle Name
Last Name
Requestor’s Email Address
Requestor’s Telephone Number with Area Code
Provide name of licensee or facility you are seeking verification for
MI Permanent ID/License Number (if applicable/known)
How do you want verification sent to recipient: (Check ONLY ONE)
EMAIL US POSTAL SERVICE
If sending via email, list recipient’s email address here
If sending via US Postal Service, provide recipient
’s name/association/US State or entity to send license verification to
Street Address to send license verification to
City
State
LICENSE TYPE
FOR OFFICE
USE ONLY
ALL OTHER HEALTH PROFESSION
CERTIFIED VERIFICATIONS CAN BE
ORDERED ONLINE AT
www.michigan.gov/miplus
.
Acupuncturist
5401-51
Athletic Trainer
2601-51
Audiologist
1601-51
Chiropractor
2301-51
Counselor
6401-51
Marriage & Family Therapy
4101-51
Massage Therapist
7501-51
Nursing Home Administrator
4801-51
Occupational Therapist
5201-51
Occupational Therapy Assistant
5202-51
Physical Therapist 5501-51
Physical Therapist Assistant 5502-51
Psychologist 6301-51
Doctoral Limited 6301-51
Masters Level 6301-51
Respiratory Therapist 4401-51
Sanitarian 6701-51
Social Service Technician 6803-51
Social Worker
Bachelors 6802-51
Masters 6801-51
Speech-Language Pathologist 7101-51
FEE PAYMENT INFORMATION FOR OFFICE USE ONLY
Submit a $15.00 fee and a separate form for EACH license
verification and type (excluding specialties) and mail to P.O. Box
30670, Lansing MI 48909.
Your check or money order, drawn from a U.S. financial
institution and made payable to the STATE OF MICHIGAN,
must accompany this request.
DO NOT SEND CASH. Fees are non-refundable.
Pharmacist Intern 5302-51
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HEALT H LICENSE VERIFICATION REQUEST Bureau of Professional (Michigan)

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Completed 9 February 2021

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