Verification of Genetic Counselor License

Date: 
03/15/2021
Document Text Version

To request verification of your Iowa Genetic Counselor license to another Board/Agency, please mail a check or money order in the amount of $25 payable to the Iowa Board of Medicine. 

Include your full name, Iowa Genetic Counselor license number, your date of birth, the Board/Agency the verification needs to be sent to, as well as the mailing address and/or email address of that Board/Agency.

IOWA BOARD OF MEDICINE
400 S.W. 8th Street, Suite C, Des Moines, IA 50309-4686
(515) 281-6641  www.medicalboard.iowa.gov

VERIFICATION OF GENETIC COUNSELOR LICENSE/REGISTRATION/ & OTHER PROFESSIONAL LICENSE

Applicant:  Complete the top portion of this form and submit to each regulatory agency that has issued you a genetic counselor license/registration or any other professional license.

Verifying Regulatory Agency: Complete and return the form directly to the Iowa Board of Medicine. In lieu of completing the form, the requested information can be provided on the agency’s official letterhead.  Any processing fees are the applicant’s responsibility.

Applicant’s Name (Print Legibly): ______________________________________________________________________

Applicant’s Date of Birth (Month/Day/Year): _____________________________________________________________

It is hereby certified that _____________________________________________________________________________

                                                                                                     (Name of Applicant)

Was issued license/registration/certification number___________________________________________________  

                                                                                                                                 (Number Issued)

On __________________________         By:                                                                                                                                         

                            (Issue Date)                                                   (Issuing State Agency)

 

Expiration date of license/registration/certification number                                                                                                            

                                                                                                                                                (Expiration Date)

Have formal disciplinary proceedings been initiated against this applicant’s license by a disciplinary authority in your state?                                                                                                                                                

Yes __________     No __________

If yes, provide details of the disciplinary action and a copy of any documentation related to the event.

Are there any pending complaints against this applicant’s license?                          Yes __________     No __________

If yes, provide details of the pending complaints and a copy of any documentation related to the event.

Has the applicant voluntarily relinquished their credential?                                      Yes __________     No __________

If yes, provide a letter of explanation.

Institutional Seal

 

(If your institution does not have an official seal, this form must be notarized.)

Completed by the Regulatory Agency for the Credential:

 

Print Name: _______________________________________________________________

 

Signature: ________________________________________________________________

 

Date (month/day/year):  __________________ Phone: ____________________________

 

Fax: _____________________ E-mail: __________________________________________

 

Electronic Verifications from the regulating agency can be sent to licensure@iowa.gov

Document Category: 

Printed from the Iowa Board of Medicine website on August 07, 2022 at 2:18pm.