Applicant: Send this notarized form to the Kansas State Board of Healing Arts. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Affidavit and Authorization for Release of Information
I, the undersigned, being duly sworn, hereby certify under oath that I am the person named in this
application, that all statements I have made or shall make with respect thereto are true, that I am the original
and lawful possessor of and person named in the various forms and credentials furnished or to be furnished
with respect to my application, and that all documents, forms, or copies thereof furnished or to be furnished
with respect to my application are strictly true in every aspect.
I acknowledge that I have read and understand the Uniform Application for Physician State Licensure and
have answered all questions contained in the application truthfully and completely. I further acknowledge
that failure on my part to answer questions truthfully and completely may lead to my being prosecuted under
appropriate federal and state laws.
I authorize and request every person, hospital, clinic, government agency (local, state, federal, or foreign),
court, association, institution, or law enforcement agency having custody or control of any documents,
records, and other information pertaining to me to furnish to the Board any such information, including
documents, records regarding charges or complaints filed against me, formal or informal, pending or closed,
or any other pertinent data, and to permit the Board or any of its agents or representatives to inspect and
make copies of such documents, records, and other information in connection with this application.
I hereby release, discharge, and exonerate the Board, its agents or representatives, and any person,
hospital, clinic, government agency (local, state, federal, or foreign), court, association, institution, or law
enforcement agency having custody or control of any documents, records, and other information pertaining
to me of any and all liability of every nature and kind arising out of investigation made by the Board.
I will immediately notify the Board in writing of any changes to the answers to any of the questions contained
in this application if such a change occurs at any time prior to a license to practice medicine being granted to
me by the Board.
I understand my failure to answer questions contained in this application truthfully and completely may lead
to denial, revocation, or other disciplinary sanction of my license or permit to practice medicine.
Notary
State of ______________________________________________, County of __________________________________________________,
I certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this applicant by: (a)
comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph
affixed hereto, and (b) comparing the applicant’s signature made in my presence on this form with the signature on his/her identifying
document.
The statements on this document are subscribed and sworn to before me by the applicant on this ______ day of _________________, 20____.
Notary Public Signature: ____________________________________________________
(NOTARY PUBLIC SEAL)
My Notary Commission Expires: ______________________________________________
Applicant:
This is a separate form
from the FCVS
affidavit and release.
If you are using FCVS,
you must complete
both FCVS and UA
affidavits. Send the
FCVS affidavit to FCVS.
Sign this form with
attached photo in the
presence of a notary
public.
Send this notarized
affidavit to:
Kansas State Board of
Healing Arts
800 SW Jackson, Lower
Level – Suite A
Topeka, KS 66612
Applicant Photograph
Securely tape or glue a recent
(less than 6 month old) front-view
2” x 2” passport-type color photo
of yourself in this square.
_________________________________________________________________________________
Applicant’s signature (must be signed in the presence of a notary)
_________________________________________________________________________________
Applicant’s printed last name
_________________________________________________________________________________
Applicant’s printed first name, middle initial, and suffix (e.g., Jr.)
_________________________________________________________________________________
Date of signature (must correspond to date of notarization)
Affidavit and Authorization for Release of Information
Applicant: Follow the instructions in the left sidebar.
Send this notarized form to the Kansas State Board of Healing Arts,
800 SW Jackson, Lower Level – Suite A, Topeka, KS 66612
-fold up- -fold up-
After folding the bottom portion upward, bring the new bottom edge to the top edge and fold to fit in a standard envelope.
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