Pain Management Clinic License forms

For questions about your Pain Management Clinic license or applying for Pain Management Clinic licensure, contact:

HB178 - Law establishing the Pain Management Clinic License

Initial Application for Pain Clinic Licensure

General Information and Application Checklist (PDF, 211.42 KB)
Initial Application (PDF, 380.46 KB)
Form A - Affidavit of Applicant Owner (PDF, 39.23 KB)
Form B - Registration of Professional Business (PDF, 35.12 KB)
Form C - Hospitals Notification Form (PDF, 40.28 KB)

Change in Pain Clinic Ownership

General Information and Checklist
Change of Owner Application (PDF, 328.9 KB)
Form A- Affidavit of Applicant Owner (PDF, 39.23 KB)
Form B- Registration of Professional Business (PDF, 35.12 KB)
Form C- Hospitals Notification Form (PDF, 40.28 KB)
DELETE OWNER CHECKLIST (PDF, 104.86 KB)
DELETE OWNER APPLICATION (PDF, 259.23 KB)

To remove a owner from the pain clinic.

Request to Add, Delete, Edit or Revise Pain Clinic Information

General Information & Checklist - Practicing Physician (PDF, 153.22 KB)
Application Form - Practicing Physician (PDF, 218.11 KB)
General Information and Checklist - Physician Assistant
Application Form - Physician Assistant
General Information and Checklist - APRN
Application Form - APRN
Checklist and General Information - Managing Employee (PDF, 132.66 KB)

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