TEXAS BEHAVIORAL HEALTH
EXECUTIVE COUNCIL
333 Guadalupe St., Ste. 3-900
Austin, Texas 78701
Tel.: (512) 305-7700
www.bhec.texas.gov
For Agency Use Only
REQUEST FOR WRITTEN VERIFICATION OF LICENSURE
TO STATE LICENSING BOARD (OR OTHER REGULATORY AGENCY)
This form must be used if you are requesting verification be sent directly to another regulatory agency.
Requestor Contact Information:
Name: ________________________________________________________________________
Telephone No.: _________________________
Mailing Address for Recipient Licensing Board or Regulatory Agency:
Agency Name: _________________________________________________________________
Mailing Address: _______________________________________________________________
Email: ________________________________________________________________________
Person for Whom Written Verification of Licensure is Requested:
Name: ________________________________________________________________________
License No.: _____________________________
The fee for written verification of licensure to a licensing board or regulatory agency is $50 per
license.
All orders must be accompanied by payment in the correct amount. Orders accompanied by an
incorrect payment amount will not be processed, and will be returned to the requestor.
Payment may be made by cash, personal check, cashier’s check, or money order. The Council does
not accept credit cards. Please make your payment payable to “TBHEC.”
Should you have any questions about this form, or need assistance in making your request, please
contact the Council’s Public Information Officer at the number listed above.