Health care professional verification form - Vermont.gov - vcic vermont 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Applicant’s Information' section. Ensure you print legibly, providing the full legal name, date of birth, and telephone number.
3. Next, complete the 'Health Care Professional Information' section with your details, including your full name, office mailing address, city, state, zip code, and telephone number.
4. In the 'Health Care Professional License Information' section, enter your license number and select the issuing state from Vermont, New Hampshire, Massachusetts, or New York.
5. Choose your licensure category from options such as Doctor of Medicine or Physician Assistant.
6. Indicate whether the patient has a debilitating medical condition by checking the appropriate boxes and providing specific diagnoses and symptoms as required.
7. Complete the 'Bona Fide Health Care Professional-Patient Relationship Statement' by checking all applicable statements regarding your relationship with the patient.
8. Sign and date the form to attest that all information is accurate and true to your knowledge.
9. Finally, ensure that the patient applicant completes their section for authorization before submission.

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