Physician Exemption Form

Fields marked with an asterisk (*) are required.

"*" indicates required fields

State of Residence*

City/County of Residence*

Name*

Submission Year*

Email*

Phone*

I certify that on September 30th of the year prior to the year entered above, I was the holder of a valid medical license issued by the Commonwealth of Virginia and, under oath, do hereby swear and affirm that I am a physician:

Check all that apply:*

who is employed by the Commonwealth of Virginia or the federal government and whose income from professional fees is less than 10% of my annual salary (you must be directly employed by the state or federal government.)

who is enrolled in a full-time graduate medical education program accredited by the American Council for Graduate Medical Education.

who has retired from active clinical practice.

whose active clinical practice is limited to the provision of services, voluntarily and without compensation, to any patient of any clinic organized in whole or in part for the delivery of health care services without charge.

who does not practice medicine in Virginia.

Signature*

Date*

Printed Name*

VA Medical License Number*

Current Address*

Street Address Address Line 2 City State ZIP Code

Important Note: Updating an address on this form does not update your address with the Virginia Department of Health Professions. You must contact VDHP to make any changes.

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Physician Exemption Form

I certify that on September 30th of the year prior to the year entered above, I was the holder of a valid medical license issued by the Commonwealth of Virginia and, under oath, do hereby swear and affirm that I am a physician:

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