Interstate Telehealth Registration Renewal Application

Instructions

To apply for an Interstate Telehealth Registration, please complete the following steps.

1. Do not delegate the completion of your Interstate Telehealth Registration renewal application to any other person. Incomplete and/or illegible applications will be returned for corrections and will not be processed by the Board.
2. Please include your printed name at the top of each page in the space provided. Make sure the contact information you provide is clear and complete. By law, you are required to notify the Board of all address changes that occur during your registration period, including updates to your email address.
3. Due to federal reporting requirements, this application requires your Social Security number. This is necessary for the Board to comply with the requirements of the federal National Practitioner Data Bank.
4. Provide complete information in each of your responses. If you answer "yes" to any of the questions, you must provide a written explanation for each each response and produce all related documentation. Your application will be considered INCOMPLETE if you do not provide the required explanations and documentation.
5. Your personal certification of accuracy and your original, dated signature is required on this application. Please review your responses carefully and ensure you have signed and dated the application.
6. Fee. Applicants must submit the applicable fee plus a processing fee of 2.25% of the total fee:

   Doctor of Osteopathic Medicine	$ 175
   Physician Assistant	$  50
7. All renewals must be submitted by 4:30 p.m. EDT on March 31, 2025. If you have any questions you may contact the board office.