Get Application For Reinstatement (8 U.s.c.a. 1101 Et Seq). E ... - Ksbha

This guide offers step-by-step instructions on completing the Application for Reinstatement as per the necessary regulations. By following this guide, you will be equipped to accurately fill out the application and avoid potential delays.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application. Ensure you have a PDF reader installed to view and edit the form.
2. Begin by filling in your full legal name. If your name differs from your identification documents, include a copy of the legal name change documentation.
3. Provide your residence, mailing, and email addresses. Note that your residence address cannot be a P.O. Box unless specified under the Safe At Home Act.
4. Enter your daytime phone number, including the area code.
5. Disclose your social security number, as it is mandated for identification. Make sure to fill in your place and date of birth.
6. Indicate your U.S. citizenship status and, if applicable, provide details regarding your non-citizen status.
7. Select the license designation you seek. You will need to choose between active, federal active, inactive, or exempt license.
8. If applying for an active license, attach proof of professional liability insurance meeting Kansas regulations.
9. Provide a comprehensive list of all professional activities since your Kansas license was canceled. Include job titles and dates.
10. List all states or jurisdictions where you have held any healthcare licenses and complete the attached Licensure Verification form.
11. Answer each of the attestation questions honestly by checking the appropriate box. Additional details may be required for any affirmative answers.
12. Detail any health-related issues that may impact your ability to practice, including obtaining necessary documentation.
13. Summarize your continuing education credits and attach relevant proof.
14. Attach a recent 2x3 photograph of yourself, ensuring it adheres to the specified guidelines.
15. Complete the oath section, ensuring it is signed and notarized before submission.
16. Pay the application fee as directed, ensuring it is enclosed with the rest of your documentation.
17. Review your application thoroughly to ensure all information is accurate and complete before saving, downloading, printing, or sharing the document.

Start your application for reinstatement today by accessing the necessary forms online.