Mississippi Board of Physical Therapy
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Public Records Request Form


Before you complete this form you must call the board office at 601-352-2918 and determine the number of pages this request will produce. There is a $1.00 per page fee.
   
Your Contact Information  
*First Name
Initial
*Last Name
Is this information for:     or   
Employer's Name (If Applicable)
*Address
Address 2
*City
*State
*Zip
*Phone
*Email
   
Please indicate how you would like to receive the records.
Board orders are in paper form only.
A disciplinary action list can be sent either by e-mail or paper form.
Email
Paper Copies
   
   
*Specific records requested: 


*These records will be used for (brief explanation):
There is a minimum $10.00 processing fee per item on all requested documents in addition to the following fees:


8 ½” x 11”              $1.00/per page

Part 3101 Chapter 5 of the Regulations contains pertinent information regarding public records request and additional fees.
   
 

If you have any questions regarding this form, you may call 601-352-2918.
Mississippi Board of Physical Therapy Website Disclaimer
Mississippi State Board of Physical Therapy
P.O. Box 55707
Jackson, MS 39296-5707
Phone: (601) 352-2918
Fax: (601) 352-2920
Email: SBoyette@msbpt.ms.gov
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