Forms—Physical Therapy Board of California

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Applicant Forms

Licensee Forms

Consumer Protection Services Forms

Application For Initial License

Form Name	Form Description	Apply Online	Download pdf copy
Initial License Application—Examination	Initial license application packet for a new graduate with no other PT/PTA license. Packet includes application instructions, Certificate of Completion (P1E) form, fingerprint information and form, and Disability Accommodation Request for Examination instructions and form.
Initial License Application—Endorsement	Initial license application packet for a PT/PTA licensed in another state. Packet includes application instructions, Certificate of Completion (P1E) form, fingerprint information, and Disability Accommodation Request for Examination instructions and form.
Fingerprint Information and Live Scan Form	To submit fingerprints to the Department of Justice (DOJ) for PTBC background check.
Certificate of Completion (P1E)	For PT/PTA education program use to confirm applicant program completion.
Request for Exam Accommodations (D1) & Instructions for Evaluators	To request examination accommodations under the Americans with Disabilities Act (ADA). You must submit this form to PTBC and indicate your request for examination accommodation when registering with the FSBPT.
PTA Equivalency Application Coursework Checklist	For PTA Equivalency applicants using coursework to qualify for initial license only. Submit with copies of official transcripts to verify coursework required pursuant to CCR 1398.47.
Verification of Clinical Experience	For PTA Equivalency applicants using clinical work experience to qualify to initial license only to verify clinical work experience pursuant to CCR 1398.47.
Work Verification for a Foreign-Educated Endorsement Applicant	For foreign-educated endorsement initial license applicants only to verify out-of-state clinical work experience pursuant to CCR 1398.26.5.
Notice of Intent to Supervise a Foreign Educated Physical Therapist (NOI) Form	For licensees requesting to supervise a foreign-educated applicant performing required period of clinical service part of the initial license application process.

Applicant Forms

Report Address or Name Changes

Form Name	Form Description	Submit Online	Download pdf copy
Address Change	To update Address of Record, Residence Address, or Email Address.
Name Change	To update licensee name on record.

Applicant/Licensee Forms

Fingerprint Information and Live Scan Form

Form Name	Form Description	Submit Online	Download pdf copy
Fingerprint Information and Live Scan Form	To submit fingerprints to the Department of Justice (DOJ) for PTBC background check.

Applicant Forms

License Maintenance

Form Name	Form Description	Submit Online	Download pdf copy
Renewal	To renew an existing Current or Inactive license.
Statement of Renewal	Self-certification of license renewal.
Inactive to Active License Status Application	To change license status from Inactive status to Active (Current) status.
Application for Retired License	Request to place license in Retired status.
Application to Restore Retired License to Active Status	Request to restore a Retired license to Active (Current) status.
Request a Verification of License	To request verification of license to another licensing jurisdiction.
Request for Duplicate Certificate	For PTs only to request duplicate wall certificate. PT and PTA pocket certificates no longer printed as of July 2020.
(CC) Activities and Coursework Checklist	To submit with copies of certificates to verify compliance with continuing competency IF REQUESTED BY BOARD.
(CC) Exemption Application	To request a continuing competency exemption. Use only if wishing to renew Active (Current) and unable to complete continuing competency as specified.
Notice to Consumers—NTC 12-01, August 2, 2012—ENGLISH	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.
Notice to Consumers—NTC 12-01, August 2, 2012—SPANISH	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.
Notice to Consumers—NTC 12-01, August 2, 2012—TAGALOG	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.
Notice to Consumers—NTC 12-01, August 2, 2012—HINDI	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.
Notice to Consumers—NTC 12-01, August 2, 2012—RUSSIAN	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.
Notice to Consumers—NTC 12-01, August 2, 2012–SIMPLIFIED CHINESE	Licensee required to provide to consumers pursuant to California Code of Regulations (CCR) 1398.15.

licensee forms

Mandatory Reporting Forms

Form Name	Form Description	Submit Online	Download pdf copy
801 Report of Settlements, Judgments or Arbitration Award	To report settlements, judgments, or arbitration awards as required by Business & Professions Code section 801 and/or 802.
805.8 Health Facility Reporting Form	To report allegations of sexual abuse or sexual misconduct against a licensee, received by a health care facility or other entity, as required by Business & Professions Code section 805.8.

Consumer Protection Services

Consumer Complaint Form

Form Name	Form Description	Submit Online	Download pdf copy
Consumer Complaint Form	To file a complaint against a licensed physical therapist or physical therapist assistant, and/or against an unlicensed person practicing physical therapy.
Authorization for Release of Patient Health Information form	Complete this form with the information from the provider you are submitting your complaint against.
Kaiser Authorization for Release of Patient Health Information	Complete this form if the treatment related to your complaint was received at a Kaiser facility.
Other Provider/Facility Authorization for Release	Complete this form for any other providers/facilities that provided treatment relevant to your complaint.

consumer protection services

Expert Consultant Forms

Form Name	Form Description	Submit Online	Download pdf copy
Expert Consultant Application	If you are interested in serving as an expert consultant for the Board, complete and submit this application along with your current curriculum vitae and a cover letter expressing why you would like to participate in the program.

licensee forms/Consumer protection services

Petition Applications

Form Name	Form Description	Submit Online	Download pdf copy
Business & Professions Code 2661.7 Petition for Modification	Reference to laws regarding Petitions for Modification and/or Termination of Probation or Reinstatement of License.
Instructions for Preparing Petition Application	Follow these instructions to prepare your Petition for Modification and/or Termination of Probation or Reinstatement of License.
Petition for Reduction of Penalty Application	Petition for Modification and/or Termination of Probation or Reinstatement of License.

licensee forms/Consumer protection services