Affidavit of Retired Physician

Are you a retired physician in Florida looking to opt out of medical liability assessments like those required by NICA (Florida Birth-Related Neurological Injury Compensation Association)?

Download the state-approved Affidavit for Exemption as a Retired Physician — a required step to legally document your retired status and avoid unnecessary fees.

✅ Florida Board of Medicine Approved

✅ NICA Exemption Compliant

✅ Ready for Signature & Notarization

🔍 What Is the Retired Physician Affidavit?

The Affidavit for Exemption as a Retired Physician is a sworn statement used to declare that you are no longer actively engaged in any compensated medical profession. By submitting this affidavit, you can avoid certain state-imposed assessments under Florida Statute Chapter 766.

This form is submitted to:

• Florida Department of Health, Board of Medicine

• NICA (Florida Birth-Related Neurological Injury Compensation Association)
  
  

📋 What’s Included in the Form?

• Statement of non-employment or current employment status

• Confirmation of medical license number and expiration

• Declaration under oath regarding exemption eligibility

• Notary public acknowledgment section

• Mailing instructions for both the Department of Health and NICA
  
  

🧾 Who Should Use This Form?

• Physicians retiring from active medical practice in Florida

• Medical professionals seeking relief from NICA assessments

• Legal representatives handling end-of-practice filings

• Estate planners and healthcare compliance advisors
  
  

📥 Get the Florida Retired Physician Affidavit (PDF)

Our downloadable version is clear, printable, and accepted by state agencies.

➡️ Click Here to Download the Affidavit (PDF)
(No email required – instant access)

✍️ Need This Notarized?

We provide online notarization services to help you finalize and file your affidavit with ease.
➡️ Schedule a Virtual Notary Session »

📫 Where to Send the Completed Form?

Mail copies to the following:

Florida Department of Health
Board of Medicine
4052 Bald Cypress Way, BIN #C-03
Tallahassee, FL 32399-1753

NICA
PO Box 14567
Tallahassee, FL 32317-4567

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