Public Health Emergency Licensure Exemption Application Form
Physician/Physician Assistant not licensed in Wyoming

This google doc was created by the Wyoming Board of Medicine. Your personal information* will never be shared with a third party and will be kept confidential.

* Last four digits of Social Security Number, Date of Birth, Gender, Medical School, and Graduation Date

Your name, address, cell phone number, and email will be shared, as required by the regulation, with the Wyoming State Health Officer to facilitate your emergency consultation with her.

If approved, your name, specialty/area of practice, and intended Wyoming practice location(s) will appear on the Wyoming Board of Medicine's website.
Full Name *
Street Address/PO Box *
City *
State *
Zip Code *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Last 4 Digits of Social Security Number *
Cell Phone *
Email *
MD/DO/PA *
Medical School *
Medical School Graduation Year *
Specialty/Area of Practice *
In what Wyoming locations and facilities do you plan to practice? *
Submit
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