The Affidavit of Healthcare Provider (VRE) is a sworn statement issued by the DC Department of Licensing and Consumer Protection (DLCP). It is labeled Part B and marked for the healthcare provider only: a representative of the provider certifies that the provider is treating a patient outside the District of Columbia for a serious health condition, and the statement is sworn before a notary public. On FillingPDF you can fill out the form online and download or print the completed PDF; the original is published by DLCP.
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What is Affidavit of Healthcare Provider (VRE) – Washington, DC?
The Affidavit of Healthcare Provider (VRE) is a sworn statement, issued by the DC Department of Licensing and Consumer Protection (DLCP), in which a healthcare provider's representative certifies that the provider is treating a patient for a serious health condition outside the District.
The form is titled "Part B. – Healthcare Provider" and carries the note "(Healthcare Provider Only)". Its footer identifies it as a page of the District of Columbia Vacation Rental Exemption Application Form, so it is one piece of that application and not a stand-alone filing.
In the certification, the representative states their name and position title, names the healthcare provider and the patient, and gives the location outside the District where treatment is provided and the dates it runs from and to. The representative certifies that the treatment is for a "serious health condition" as defined by D.C. Official Code § 32-541.01(20), that they are authorized to provide the information on behalf of the healthcare provider, and that all information submitted is true to the best of their knowledge.
The affidavit is completed with the representative's printed name, position title, email and phone number, the healthcare provider's email and phone number, and the representative's signature. A notary public completes the jurat ("Subscribed and sworn before me, a Notary Public"), with seal, date and commission expiration.
Who needs to file Affidavit of Healthcare Provider (VRE) – Washington, DC?
A representative of a healthcare provider completes this affidavit. The form is marked "(Healthcare Provider Only)", and the representative must be authorized to provide the information on behalf of the provider.
The statement concerns a patient whom the provider is treating at a location outside the District of Columbia, for a "serious health condition" as defined by D.C. Official Code § 32-541.01(20). The form does not describe how the patient or the vacation rental owner is connected to the exemption; the DLCP Vacation Rental Exemption Application Form named in the footer is where that application is made.
The form asks for the representative's name, position title and contact details, so it is signed by the representative personally and not by the patient. A notary public must also complete the sworn portion of the form. The form names no other signer and has no section for anyone to sign on the representative's behalf.
When to file Affidavit of Healthcare Provider (VRE) – Washington, DC
The form prints no due date of its own. Its footer places it within the District of Columbia Vacation Rental Exemption Application Form, so it travels with that application and not as a separate filing.
The dates that matter on the affidavit itself are the treatment dates: the representative enters the date treatment starts and the date it ends at the location outside the District. The "Today's Date" line in the notary block records the date of the notarization. For any filing deadline that applies to the exemption application, check DLCP.
How to fill out Affidavit of Healthcare Provider (VRE) – Washington, DC
Confirm who completes the form
Part B is for the healthcare provider only. The person completing it must be a representative authorized to provide the information on the provider's behalf.
Enter the representative's name and title
In the first certification line, enter the representative's name and position title ("I, [Representative Name], certify that I am [Position Title]").
Name the provider and the patient
Enter the healthcare provider's name and the patient's name in the sentence stating that the provider is providing treatment for the patient.
Enter the treatment location and dates
Write the location outside of the District where treatment takes place, then the start date and end date in the "from ... to ..." fields.
Complete the authorization statement
In the line stating that you are authorized to provide this information, enter the name of the healthcare provider you represent. The text on serious health condition (D.C. Official Code § 32-541.01(20)) is preprinted.
Add printed name and contact details
Enter the representative's printed name and position title, the representative's email and phone number, and the healthcare provider's email and phone number.
Sign before a notary public
The representative signs on the Signature of Representative line. The notary completes the sworn statement with seal, notary name, today's date and commission expiration.
Review and download the completed PDF
Check the names, dates, location and contact details, then download or print the completed PDF from FillingPDF and take it to the notary for the sworn portion.
How to submit Affidavit of Healthcare Provider (VRE) – Washington, DC
The form names no mailing address, portal, office or appointment of its own. Its footer shows it is a page of the District of Columbia Vacation Rental Exemption Application Form issued by DLCP, so it is submitted as part of that application and through whatever channels DLCP gives for it.
- Complete the affidavit and have the representative sign it before a notary public, who adds the seal, today's date and commission expiration.
- Keep the signed and notarized original ready for the application package.
- Ask DLCP, or check the application it belongs to, for the exact delivery details and any fee.
FillingPDF lets you fill out and download the PDF; submission follows the DLCP channels described above.
Common mistakes to avoid
- Having someone other than an authorized representative of the healthcare provider complete the form, which is marked "(Healthcare Provider Only)".
- Signing the affidavit without a notary public completing the jurat, seal, date and commission expiration lines.
- Entering a treatment location inside the District; the form asks for a location outside of the District.
- Leaving the treatment start or end date blank in the "from ... to ..." line.
- Omitting the email and phone number of the representative or of the healthcare provider; the form asks for both.
- Leaving the representative's printed name or position title blank, which the certification statement also relies on.
- Treating the affidavit as a complete filing; its footer shows it is a page of the District of Columbia Vacation Rental Exemption Application Form.
Frequently asked questions
What is the Affidavit of Healthcare Provider (VRE)?
It is a DLCP sworn statement, labeled Part B, in which a healthcare provider's representative certifies that the provider is treating a patient for a serious health condition at a location outside the District. Its footer shows it belongs to the District of Columbia Vacation Rental Exemption Application Form.
Who fills out the Affidavit of Healthcare Provider?
A representative of the healthcare provider who is authorized to give the information on the provider's behalf. The form is marked "(Healthcare Provider Only)" and asks for the representative's name, position title, email, phone number and signature.
Does the Affidavit of Healthcare Provider have to be notarized?
The form includes a jurat reading "Subscribed and sworn before me, a Notary Public," with lines for the notary's seal, name, today's date and commission expiration. The notary completes that block after the representative signs.
Does the treatment have to take place outside the District?
The affidavit asks for a "Location Outside of the District" and the dates treatment runs from and to. The form is built around treatment outside the District, so enter that location and the treatment dates.
What does "serious health condition" mean on this form?
The form says the term is as defined by D.C. Official Code § 32-541.01(20). The affidavit does not restate the definition, so check that code section before the representative certifies the statement.
Where do I submit the Affidavit of Healthcare Provider (VRE)?
The form lists no address or portal. Its footer names the District of Columbia Vacation Rental Exemption Application Form, so it goes with that application through the channels DLCP gives for it. Contact DLCP to confirm delivery details.
Can I fill out the Affidavit of Healthcare Provider online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit, file or notarize the form; the notary and DLCP's channels still apply.
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