Mddo-verification-state-licensure 20210716 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the upper portion of the form. Enter your Last Name, First Name, and any Other Names you have been known by. Include your Middle Name, Date of Birth (DOB), and the last four digits of your Social Security Number (SSN).
3. Next, provide your License Number and Date Issued. Fill in your Street Address, City, State, and Zip Code.
4. Authorize the release of information by signing and dating the form at the bottom of this section.
5. Once completed, send this upper portion directly to each State Board for processing. Ensure you check with each board regarding any required fees.
6. The State Board will complete the lower portion of the form. They must sign it and affix their seal before returning it directly to the Oregon Medical Board.

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