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Board Designated Request

For Physicians and Physician Assistants

PDC Designated Board Request

If you are a physician or physician assistant who needs to have a Physician Data Center Profile sent directly to yourself or to a state medical board for licensure purposes, please complete the request form by typing directly in the required fields. Once you have completed the form, you may save it and email it to or print the form and fax or mail to the number or address provided on the form. Please complete a separate form for each state medical board requesting a report.