Page 1 of 3 (Rev.
2018-08)
Department of Health
Maryland State Board of Massage Therapy Examiners
4201 Patterson Avenue, Suite 301
Baltimore, Maryland 21215
Office Main Telephone: 410-764-4738 Office Fax: 410-358-1879
REACTIVATION APPLICATION 2018 - 2020
(Only For Licenses / Registrations Expired 24 Months or Less)
NOTE: IF YOU ARE NOT SURE OF YOUR LICENSE / REGISTRATION STATUS, ACCESS THE ‘VERIFICATION’ LINK ON THE BOARDS OFFICIAL WEBSITE:
www.health.maryland.gov/massage
REACTIVATION FEES:
LICENSE MASSAGE THERAPIST =L.M.T. REGISTERED MASSAGE PRACTITIONER = R.M.P.
Payment must be by personal check, certified check, or money order payable to ‘MD State Board of Massage Therapy Examiners’
and MAILED TO: 4201 Patterson Avenue, Suite 301, Baltimore, MD 21215, Attn: Adrienne Congo, MS, Deputy Director
♦ REACTIVATION Application Fees for (LMT) – $376.00 (Includes $100 reactivation fee, $250 renewal fee, and the mandatory
assessment of $26 by the Maryland Health Care Commission which applies to all Maryland Health Care Practitioners (LMT’s
only). Other requirements apply > see page 2.
♦ REACTIVATION Application Fees for (RMP) – $350.00 (Includes $100 reactivation fee and $250 renewal fee.
To further its commitment to equal opportunity, the Board of Chiropractic & Massage Therapy Examiners request applicants to provide VOLUNTARILY,
the following information. This information will be used for statistical purposes only by authorized personnel.
Race/ethnic identification – please check all that apply:
1. Hispanic or Latino origin (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race).
2. American Indian or Alaska Native (a person having origins in any of the original peoples of North or South America, including Central America, and who main-
tain affiliations or community attachment).
3. Asian (a person having origin in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for ex. Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam).
4. Black or African American (a person having origins in any of the black racial groups of Africa).
5. Native Hawaiian or other Pacific Islander (a person having origins in the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).
6. White (a person having origins in any of the original peoples of Europe, the Middle East or North Africa).
7. Other
____8. Prefer Not to Answer
____9.U.S. Military Service
Gender Male Female Other
COMPLETE THE FOLLOWING INFORMATIONAL SECTIONS WITH LEGAL AND ACCURATE INFORMATION. THIS IS A FILLABLE PDF OR PRINT LEGIBLY OR TYPE.
FAILURE TO PROVIDE UPDATED INFORMATION PER INSTRUCTIONS ON THIS APPLICATION WILL RESULT IN THIS APPLICATION BEING RETURNED TO YOU.
MY NAME HAS LEGALLY CHANGED – ATTACH NAME CHANGE FORM MY ADDRESS HAS CHANGED - ATTACH ADDR. CHANGE
INFORMATION ON FILE WITH THE
FORM
FULL NAME: CONTACT PHONE:
LEGAL ADDRESS (include apt#, suite #’s):
F
CITY: STATE: ZIP: E-MAIL:
BOARD
(A). WORKERS’ COMPENSATION INSURANCE INFORMATION (Required per Health Occupations Art. §1-202): Please direct inquiries to
410-864-5100 or visit the WCC website at http://www.wcc.state.md.us for more info.
I HEREBY CERTIFY THAT: (Check One)
I do not practice in Maryland. I practice in Maryland and am NOT an employer. I practice in Maryland and employ one or more persons.
Listed below is my required Workers’ Compensation Insurance information.
Insurance Co.: Policy No.: _ Exp. Date:
2014-2016 REINSTATEMENT Page (1 of 3
NOTE: YOU MAY NOT PRACTICE MASSAGE THERAPY UNTIL YOU HAVE THE VALID BOARD ISSUED LICENSE OR REGISTRATION
Page 2 of 3 (Rev. 2018-08)
(B). PROFESSIONAL COMPETENCY & BACKGROUND
Please write “YES” or “NO” to each question below. All “yes” answers must be explained in your own words on a separate sheet. Include all
details, dates, and resolutions to the matter. NOTE: ALL QUESTIONS MUST BE ANSWERED OR APPLICATION WILL BE RETURNED.
PROVIDE ACCURATE, COMPLETE AND COMPREHENSIVE ANSWERS TO AVOID DELAYS OR SANCTIONS.
1. Since your last active status, have you been addicted to, or is currently dependent on alcohol,
any drug (prescription or non-prescription), or any controlled substance?
2. Has ANY state licensing, certification or disciplinary Board or comparable body in any federal,
state, municipal or Armed Forces ever taken any action against your license, certification, or registration, including this Board?
3. Since your last active status, have there been any outstanding complaints, investigations, charges, or
allegations pending against you by any of the aforementioned bodies?
4. Since your last active status, have you had a physical or mental illness, or injury/disability that impaired or
impairs your ability to practice?
5. Since your last active status, have you had any court proceedings, pled guilty, nolo contendere,
no contest, or been convicted or received probation before judgment of any criminal act, including DWI or DUI of alcohol or controlled
substances?
6. Since your last active status, has any hospital, HMO, managed care organization, or related healthcare
entity or employer denied you privileges or employment, denied application for employment, or did not renew your contract for a reason or
reasons related to your practice?
7. Since your last active status, has a malpractice civil suit, civil suit or action been filed against you or has
a claim been made against you or a settlement or award had been made against you relating to your practice?
(C). CONTINUING EDUCATION (TOTAL REQUIRED = 24 Hours) & CPR CERTIFICATION: New revised regulations – Jan. 6, 2014 are:
1 hour in diversity and Cultural Competency + 3 hours in Professional Ethics or Jurisprudence + 3 hours in Communicable
Diseases including AIDS/HIV + 17 Massage Related (techniques) courses = 24 CEUS.
You must remit with your application, copies of your CEU certificates (dated November 1st through October 31st of the biennial window [the
dates after the last expiration of your last active license/registration]) AND a copy of your current valid qualification in CPR along with this
Reactivation Application. Reactivation forms submitted WITHOUT copies of valid CEU completion certificates and a copy of your
active CPR (Healthcare Provider Level) for LMTs or card (front/back); WILL NOT BE PROCESSED and will be returned to you
for resubmission.
(D).
Active LMT Fee: $276.00 (Renewal Fee Includes Health Care Commission Fee of $26.00) $
Active RMP Fee: $250.00 $
Reactivation Fee: $100.00 (In addition to the above renewal fee) $
Duplicate Request Fee: $40.00 X _____ ($20.00 during Biennial Renewal Period – Aug. 30th – Nov. 30th even yr.)$
Check(s) or money order(s) number(s): TOTAL FEES $
I AFFIRM AND ATTEST THAT THE INFORMATION I HAVE GIVEN ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF
MY KNOWLEDGE AND BELIEF.
PRINT/TYPE APPLICANT FULL NAME APPLICANT SIGNATURE LIC. / REG. No. DATE
BOARD OFFICE USE ONLY
Date Received to Office: _______ Review Date: _______ Int.: _______
CHRC UNIT: Investigator Sign Off: ______ Check Date: _______ APPROVAL DATE: _______ Int.: _______
Check Number: _______ Entered Database: _______ Int.: _______
Fwd. to D & C Committee Date: ______ Lic./Reg. Number: _______ Control #:_______ Int.: _____
(If Forwarding is applicable)
(if applicable)
Page 3 of 3 (Rev. 2018-08)
Professional Competency & Background Explanation
(For yes answers to Questions 1-7 of Section B)
Note: If not applicable; disregard this page. If you answered yes; complete information or
indicate specific documents you attached.
