Forms

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Prescriptive Authority forms

Collaborative Agreem​ent Form​​

Dissolvement of Collaborative Agreement

Guidelines for Completing Collaborati​ve Agreement Form


Dialysis Tech Forms

Dialysis Tech Applicant Employment Certification Form

Dialysis Tech Applicant Good Moral Character Certification Form

Dialysis Tech Applicant Program Administrator Competency Form


Other Forms

APRN Verification Form
(Use this form to send to other states and have them verify your APRN license with us)

RN Verification Form
(Use this form to obtain a verification from states that do not participate in NURSYS)


Complaint Form

 

Fee Schedule:

 (there may be a small additional transaction fee for online applications)

Address Change No Charge
Duplicate License $10.00
Endorsement without Temporary Permit $100.00 (Money Order or Cashier's Check)
Endorsement with Temporary Permit $125.00 (Money Order or Cashier's Check)
Endorsement with 90-day Temporary Permit ONLY $25.00 (Money Order or Cashier's Check)
Licensure by Examination $70.00 (Money Order or Cashier's Check)
RN Renewal $67.00
Advanced Practice Application $35.00
Advanced Practice Renewal $35.00
Limited Prescriptive Authority $125.00
Name Change $10.00
Name Change with License Replacement $10.00
Reinstatement from Lapsed Status $115.00
Reinstatement from Inactive Status $25.00
Transcript Photocopy $5.00
Verification to Another Nursing Board
or Certification Body
via NURSYS
Volunteer License No Charge
Working Without a Valid License Disciplinary fees
West Virginia RN Board
5001 MacCorkle Ave, SW, South Charleston, WV 25309 (304) 744-0900