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Pain Management Clinic License forms

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

contact:

Contact Licensure Specialist

Contact for RCP applicants and Pain Clinic applicants

[email protected]

HB178 - Law establishing the Pain Management Clinic License

Initial Application for Pain Clinic Licensure

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

Change in Pain Clinic Ownership

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

To remove a owner from the pain clinic.

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

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