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MARYLAND STATE BOARD OF CHIROPRACTIC EXAMINERS 4201 Patterson Avenue, Suite 301 Baltimore, MD 21215 (410)7644726 www.health.maryland.gov/chiropracticAPPLICATION FOR LICENSURE BY WAIVER FOR VISITING
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To fill out the Maryland Department of Health form, follow these steps:
02
Obtain a copy of the form from the official Maryland Department of Health website or local health department office.
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Read the instructions and requirements carefully to ensure you have all the necessary information and documentation.
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Begin by providing your personal information, such as full name, address, contact details, and date of birth.
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Fill out the sections related to your medical history, including any pre-existing conditions, medications, and allergies.
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If applicable, provide details about your employment, insurance coverage, and any healthcare providers you are currently seeing.
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Answer any additional questions specific to the purpose of the form, such as immunization records or patient consent.
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Double-check all the information you have entered to ensure accuracy and completeness.
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Sign and date the form in the designated area.
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Make copies of the completed form for your records before submitting it to the Maryland Department of Health or the designated recipient.
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Follow any additional submission instructions provided, such as mailing, emailing, or hand-delivering the form.
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Note: It is always recommended to consult the instructions provided with the form or seek assistance from the Maryland Department of Health if you have any doubts or questions.

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The Maryland Department of Health plays a crucial role in ensuring the well-being and healthcare needs of Maryland residents and offers various programs, services, and guidance to meet public health goals.
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The Maryland Department of Health is a state government agency responsible for public health in Maryland.
Healthcare facilities and providers in Maryland are required to file the Maryland Department of Health.
The Maryland Department of Health form can be filled out online or submitted by mail with the required information.
The purpose of the Maryland Department of Health is to monitor and promote public health in the state.
Information such as patient demographic data, health conditions, treatments provided, and outcomes must be reported on the Maryland Department of Health form.
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