Forms and Applications

Act 125/Envision School Health Program

• Certificate of Achievement
• Envision Program enrollment form

Act 125/Envision home page

Asbestos and Lead Program

• Essential Maintenance Practices Compliance Statement: Residential Rental Properties (pdf)
  • Extra Side 2 - Compliance Statement for Residential Rental Properties
• Essential Maintenance Practices Compliance Statement: Child Care Facilities
• Asbestos Contractor Entity Application Form (pdf)
• Asbestos Contractor Individual Application Form (pdf)
• Asbestos Training Provider Application Form (pdf)
• Asbestos Abatement Project Permit Application Form (pdf)
• Asbestos Small Scale Short Duration Form (pdf)
• NESHAP Notification (pdf)
• NESHAP form general instructions (pdf)
• Lead Contractor Entity Application Form (pdf)
• Lead Contractor Individual Application Form (pdf)
• Lead Abatement Project Permit Application Form (pdf)
• Lead Training Provider Application (pdf)

Asbestos and Lead Program home page

Birth, Death, Civil Union, Marriage, DIvorce Certificate Order Forms

• New records - Last five (5) years
  Order from the Department of Health

• Older records - More than five (5) years
  Order from the Vermont State Archives and Records Administration
  • Contact State Archives
    Email: vitals@sec.state.vt.us
    Phone: (802) 828-3286
    Fax: (802) 828-3710

Vital Records home page

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Board of Medical Practice

Board of Medical Practice home page

Fees (Current and Furture)

• Current and Future Fee Schedule

Physician

• Initial License Application for Physicians
  • 2010 Physician Renewal Application
• License Reinstatement Application for Physicians
• Initial Application for Limited Temporary Physician License
  • Renewal Application for Limited Temporary Physician Licensee

Podiatrist

• Initial Application for Podiatrists
  • Reinstatement Application for Podiatrists
• Initial Application for Limited Temporary Podiatrist License

Physician Assistant

• Initial License Application for Physician Assistants
  • Application for Additional Certification as a Physician's Assistant
  • Renewal application for Physician Assistants
  • Notification to the Board of Termination of Employment Contract

Anesthesiologist Assistant

• Initial Application for Anesthesiologist Assistant Certification
  • Anesthesiologist Assistant renewal

Other Medical Board forms

• Complaint form

Prescriber Data-Sharing Program

• Consent Form
• Revocation of Consent Form
• Fact Sheet for Prescribers
• Frequently Asked Questions

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Emergency Medical Services

• Students and recertifying EMS providers
• EMS course and exam coordinators
• Applications for reciprocity
• Service managers/administrators

EMS home page

Food and Lodging Program

• Application for License to Operate a Food & Lodging Establishment (pdf)

Food and Lodging Program home page

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HIV/AIDS Medication Assistance Program, Dental Care Assistance Program

• HIV/AIDS Assistance Programs Application and Instructions (pdf)
• Physician Verification of HIV Status form (pdf)
• Release of Information Form (pdf)

HIV/AIDS home page

Immunization Program

• Vaccine for Children - Program Enrollment & Varicella Agreement
• Provider Resource Materials Request Form

Immunization Program home page

Immunization Registry

• Confidentiality Agreement form

Immunization Registry Program home page

Ladies First

Provider forms

• Ladies First/EDS Provider Enrollment Form (pdf )
• Authorization for Electronic Funds Transfer (pdf)
• EDI Registration (pdf)
• Electronic Data Interchange Trading Partner Agreement (pdf)

Ladies First home page

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Mental Health

• Adult mental health forms
• Children's mental health forms
• State hospital forms

Department of Mental Health home page

Public Health Laboratory

• Water and Radon Test Order Form (pdf)
  • Water Test Order Form Supplement (pdf)
    Provides descriptions of test groupings listed on the Order Form above.

Public Health Laboratory home page

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Radiological Health

• Registration of X-Ray Equipment/Sources of Ionizing Radiation (pdf)

Radiological Health home page

WIC: Women, Infant and Children Program

• Enrollment form (pdf)
• Completing the Proof of Delivery form

WIC home page

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