Louisiana state board of medical examiners

Louisiana State Board of Medical Examiners

Physical & Application Processing Address: 630 Camp Street, New Orleans, LA 70130

General Correspondence Mailing & Criminal Background Check Address: P.O. Box 30250, New Orleans, LA 70190-0250
PHYSICIANS

QUALIFICATIONS / INSTRUCTIONS

(November 2017)

Qualifications for Licensure - International Medical Graduates

• 
  Be at least 21 years of age and of good moral character;
  

• 
  Be a citizen of the United States or possess valid and current legal authority to reside and work in the United States duly issued by the commissioner of the Immigration and Naturalization Service;
  

• 
  Possess a Doctor of Medicine degree duly issued by a medical school approved by the board. This diploma must be in English; if not, must be accompanied by a certified translation into English;
  

• 
  Applicant must have completed three years of ACGME approved residency training in the United States or Canada in the same specialty;
  

• 
  Have taken and passed FLEX/USMLE Steps 1, 2, and 3 or a combination thereof. (There is no limit on step 1, four on Step 2 and four on step 3).
  

• 
  Have taken and passed the ECFMG examination and have a valid certificate;
  

• 
  If a medical competency examination has not been taken within 10 years of application, the applicant must be board certified or re-certified through the American Board of Medical Specialties within the past ten years or the applicant must take and pass SPEX (Special Purpose Examination) administered through the Federation of State Medical Boards, Inc.
  

Qualifications for Licensure - U.S./Canadian Graduates

• 
  Be at least 21 years of age and of good moral character;
  
• 
  Be a citizen of the United States or possess valid and current legal authority to reside and work in the United States duly issued by the commissioner of the Immigration and Naturalization Service;
  

• 
  Possess a Doctor of Medicine degree duly issued by a medical school approved by the Board. The diploma must be in English. If not, must be accompanied by a certified translation into English;
  

• 
  Completed a year of ACGME approved internship training in the United States or Canada;
  

• 
  Have taken and passed either the state board examination, National Boards Parts 1, 2, and 3, FLEX, USMLE, COMLEX-USA, NBOME or a combination thereof. (There is no limit on step 1, four on Step 2 and four on step 3).
  

• 
  If a medical competency examination has not been taken within 10 years of application, the applicant must be board certified or re-certified through the American Board of Medical Specialties or the American Osteopathic Association within the past ten years or the applicant must take and pass SPEX (Special Purpose Examination) administered through the Federation of State Medical Boards, Inc or COMVEX-USA administered by the National Board of Osteopathic Examiners.
  

Instructions for Completing the Application


PAGE 1

Licensure Category- Indicate your licensure category
Location – Indicate where and when you are locating in Louisiana
FCVS- Indicate if you have applied to FCVS
Address - Indicate your current Business, Home, and Preferred Mailing Address. (The Business address will appear on our website at www.lsbme.la.gov )
Specialty- List specialties and board certifications
Identification- Answer all identification questions
Personal Appearance – A face to face meeting with a member of the board or its designee is required under certain circumstances.  If applicable, once the application is complete, you will be notified via email who to contact to schedule the meeting.  In some cases, you may be able to conduct the meeting by FaceTime.

PAGE 2

Medical Education - List the professional education - the place where you received your Medical/Osteopathic Degree. List all professional schools attended in chronological order
Postgraduate Medical Training - List all postgraduate training done in the United States or Canada in chronological order
Practice History and Non-Professional Activities - List the practice history and non-medical/professional related activities here. Do not include training
Examination History - List name, date, location and result of each examination
Telemedicine – Answer all questions and necessary paperwork, if applicable.


Submit application along with:

• 
  Oath or Affirmation
  
• 
  Third Party Authorization
  
• 
  Statement of Legal Name
  

Oath or Affirmation - Read, answer and have this form notarized. Any “yes” answer(s) must be accompanied by a notarized affidavit. The applicant must explain in detail the incident(s) in which he/she is answering yes to and have the explanation typed written and notarized. This includes offenses that may have occurred as a juvenile and that may have been expunged from your record.

NOTE: If criminal history is found that you did not disclose, you will be required to submit a new Oath or Affirmation, a notarized affidavit as to why you did not disclose the information and a new processing fee equal to the initial licensure fee. It is important that you answer question 3 accurately and truthfully. Do not take the advice of friends, lawyer, etc.
Third Party Authorization- Read and have this form notarized.
Statement of Legal Name - Record your name as it appears on each document listed that applies to you. This form must also be completed by any person whose name is not the same as the name on the birth certificate. This form must be notarized.
GENERAL INSTRUCTIONS

Background Check - NOTE: If you are a physician on a current LSBME training permit, you do not need to do another background check when applying for full licensure.

LSBME conducts background checks as part of the application process.  Instructions and forms can be downloaded from our website or materials can be requested by:

• 
  Mail: LSBME, Attn: CBC, 630 Camp Street, New Orleans, LA 70130 
  
• 
  E-Mail: [e-mail] 
  
• 
  Phone: [phone]
  

Applicants with criminal history may expect delays in the application process

Notarized Birth Certificate - The applicant must submit a notarized copy of the birth certificate or a notarized copy of the passport (expired passports are acceptable). If the applicant submits a passport, the applicant must include a written explanation of the reason the birth certificate is not available.
Valid Visa - Applicants who are not native-born citizens of the United States must show proof of legal entry into the United States to work or reside by presenting:

• 
  Original Certificate of Naturalization
  
• 
  Birth Certificate establishing birth to U.S. citizens traveling abroad
  
• 
  Valid Visa issued by the Department of Immigration and Naturalization (INS)
  

• 
  Marriage license and/or court decree of the applicant who applies in a name different from the name on the birth certificate.
  

FEES ARE NOT REFUNDABLE and must accompany the application - $382.00 (MD/DO). All fees must be paid to LSBME via Check or Money Order only.  For individuals still desiring to pay by check it should be noted that should a check be returned as NSF you will be charged a $35.00 NSF fee and you will be required to resubmit the initial licensure fee in the form of a money order and there will be an additional charge of $23.00.

Other Information
Check the status of your initial application

To check the status of your initial application, visit our website at www.lsbme.la.gov. Click on For the Practitioner>Check the Status of your Initial Application. Enter your last name, date of birth and last 4 of your social security number. This page will show you what has been received by the LSBME and what is still pending. Please refer to this webpage PRIOR to calling the LSBME.

Communication with the Board

If you need to speak to a Licensing Analyst please call our Licensure Dept. @ 504-568-6820 x115 or email [e-mail].  

Communication from the Board

After an application is received and reviewed, applicants will receive a deficiency report via e-mail (or by regular mail if requested); therefore, it is the applicant’s responsibility to check their e-mail and to keep their e-mail address current with LSBME. The deficiency report will list what is outstanding from the applicant’s file at the time of submission.

Contact Addresses

Federation of State Medical Boards, Inc. (FSMB)

400 Fuller Wiser Road, Suite 300

Euless, TX 76039-3855

[phone]

Website: www.fsmb.org

Educational Council for Foreign Graduates (ECFMG)

3624 Market Street, Fourth Floor

Philadelphia, PA 19104-2685

[phone]

The National Board of Medical Examiners

3750 Market Street

Philadelphia, PA 19104-3102

[phone]

The National Board of Osteopathic Examiners, Inc.

8765 West Higgins Rd, Suite 200

Chicago, IL 60631-4101

[phone]

American Board of Medical Specialties

1007 Church Street, Suite 404

Evanston, IL 60201-5913

[phone]

Louisiana State Board of Medical Examiners

630 Camp Street

New Orleans, LA 70130

[phone]

Louisiana State Board of Medical Examiners
Initial Application for Licensure for Physicians

FILL IN ONLINE PRIOR TO PRINTING
Intended Location/Date in Louisiana: City       Date:      

Have you applied for FCVS for credentials verifications? Yes No Check one: MD DO

NAME: LAST      		FIRST      				MIDDLE      			SUFFIX (SR, JR)      		TITLE (MD/DO)      
SOCIAL SECURITY NUMBER      		DRIVER’S LICENSE # & STATE      				CONTROLLED SUBSTANCES PERMIT #’S DEA:       STATE:       FED:      
BUSINESS ADDRESS: *This address will appear on the LSBME website. STREET & NO. (DO NOT USE P.O. BOX)      						CITY      				STATE      
ZIP + 4      	COUNTY/PARISH      		COUNTRY (IF NOT U.S.)      				PHONE:      
							FAX:      
							EMAIL:      
HOME ADDRESS: STREET & NO.      					CITY      			STATE      
ZIP + 4      	COUNTY/PARISH      			COUNTRY (IF NOT U.S.)      			PHONE:      
							CELL:      
							FAX:      
							EMAIL:      
PREFERRED MAILING ADDRESS: STREET & NO. *Renewal notices will be sent to this address.      					CITY      			STATE      
ZIP + 4      	COUNTY/PARISH      			COUNTRY (IF NOT U.S.)      			PHONE:      
							FAX:      
							EMAIL:      
SPECIALTY: 1)       2)       3)       4)      
ABMS/AOA SPECIALTY BOARD CERTIFICATION/YEAR: 1)       2)       3)       4)      
IDENTIFICATION: RACE:       SEX      WEIGHT:       HEIGHT:       EYES:       HAIR:       MARKS:       MARITAL STATUS:       SPOUSE’S FULL NAME:       PLACE OF BIRTH:       DATE OF BIRTH:       ARE YOU A U.S. CITIZEN?       IF NOT NATIVE BORN CITIZEN OF THE U.S. GIVE FOLLOWING INFORMATION: TYPE OF VISA:       IF NATURALIZED, CERTIFICATE #:       INS #:       PETITION #       DATE ISSUED:       DISTRICT COURT THROUGH WHICH ISSUED:       U.S. ACTIVE DUTY: BRANCH:       DATES SERVED:       TYPE DISCHARGE:       HAVE YOU EVER HELD ANY TYPE OF LICENSURE IN LOUISIANA? Yes No IF YES, TYPE & #:      
PERSONAL APPEARANCE State the preferred location for personal appearance with original credentials. Personal appearance shall not be made until application is otherwise complete. If does not apply, mark “X” here: 
MD/DO Baton Rouge Lafayette New Orleans Rayne Shreveport Slidell Video Conference

Name (Printed or typed):      SS#:      

Professional/Medical School      

Post Graduate Training Program      

City, State & Country, if not U.S.      

City, State & Country, if not U.S.      

Month/Year Started      

Month/ Year Ended      

Degree      

Month/Year Started      

Month/Year Ended      

Specialty      

Post Graduate Training Program      

Post Graduate Training Program      

City, State & Country, if not U.S.      

City, State & Country, if not U.S.      

Month/Year Started      

Month/Year Ended      

Specialty      

Month/Year Started      

Month/Year Ended      

Specialty      

Post Graduate Training Program      

Post Graduate Training Program      

City, State & Country, if not U.S.      

City, State & Country, if not U.S.      

Month/Year Started      

Month/Year Ended      

Specialty      

Month/Year Started      

Month/Year Ended      

Specialty      

Practice History and Non-Professional Activity (Do NOT include Training) Attach separate 8 ½ x 11 sheet if necessary. Account for ALL time not specified above, in chronological order, from Professional/Medical school to the present.

From Month/Year

To Month/Year

City

State or Country

Employer or practice setting (Clinic, Hosp., Solo/Group, Etc.)

Specialty or Activity

      /      

      /      

     

     

     

     

      /      

      /      

     

     

     

     

      /      

      /      

     

     

     

     

      /      

      /      

     

     

     

     

      /      

      /      

     

     

     

     

Have you ever taken any of the following written exams: National Boards, other State Boards, USMLE, FLEX, COMLEX-USA, NBOME, SPEX/COMVEX-USA Yes No If yes, list name, location, date and result of each examination; failures must also be disclosed. Each examination agency must submit an original official Examination History Report directly to the LSBME. NOTE: Louisiana has a four time limit on all exams.

Examination (indicate # of times taken)

Date

Result (Pass/Fail)

     

     

     

     

     

     

     

     

     

Have you ever been licensed to practice medicine in any state, territory, province, or country? Yes No If yes, list the State, License Number and Issue Date of license. Please include permanent, temporary, training, provisional, limited or permit. Verification is required for each. Attach separate 8 ½ x 11 sheet if necessary.

State

License Number

Issue Date

     

     

     

     

     

     

TELEMEDICINE – Complete the below if you will be practicing Telemedicine

I have completed the online Telemedicine course: Yes No

Are you going to be practicing Telemedicine in LA? Yes No

Are you going to be practicing Telemedicine across State lines? Yes No

Description of how telemedicine will be used:      

Identify address for the custodian of medical records?      

What procedure/arrangements are in place for the patient to receive back-up, follow up and emergency care?      

Name (Printed or typed):       SS#:      

Louisiana State Board of Medical Examiners
Oath or Affirmation - INITIAL LICENSURE – Physicians & Podiatrists

NOTE: Yes answers must be explained in an affidavit (a typed, notarized explanation in your own words).

		Yes	No
1	In the 10 years prior to this application have you had any physical injury or disease or mental illness or impairment, which could reasonably be expected to affect your ability to practice medicine or other health profession?		
2	In the 10 years prior to this application have you been referred to or obtained treatment for a substance abuse disorder including alcohol abuse?		
3	Have you EVER been arrested (cited, charged with, convicted of or pled guilty or nolo contendere) to a violation of any municipal, state or federal statute? Include any that have been expunged or judicially removed for any reason. (You do not have to report misdemeanor traffic offenses or traffic ordinance violations unless they involve alcohol or drugs).		
4	Have you failed a professional licensure or certification examination (any step/part of FLEX, USMLE, NBME, NBOME, COMLEX-USA, SPEX/COMVEX-USA or PMLexis)?		
5	Has your application for any professional license, certificate, or registration been denied by any state licensing board or federal authority?		
6	Has your professional license, certificate, or registration been the subject of investigation or revoked, suspended, probated, restricted, reprimanded, limited, or subjected to any other disciplinary action by any state licensing board or federal authority?		
7	Have you voluntarily surrendered any professional license, or agreed with any licensing authority not to seek re-licensure in order to avoid disciplinary action, investigation or inquiry?		
8	Was your application for staff or clinical privileges at any hospital, clinic, or other health care institution denied?		
9	Were you the subject of an inquiry or investigation by any hospital, clinic, or other health care institution which resulted in the suspension, restriction, probation or other limitation on your affiliation or staff or clinical privileges; including remediation and/or non-disciplinary sanctions?		
10	Did you surrender or fail to renew staff or clinical privileges at any hospital, clinic, or other health care entity in lieu of investigation, while under investigation or while you were the subject of disciplinary proceedings?		
11	Were you the subject of disciplinary action, placed on academic probation, or asked to undergo additional training or remediation during your professional training (as a student, intern, resident, fellow, or other trainee)?		
12	Did you leave any professional training program as defined above before completion?		
13	Was your professional training program extended for any reason?		
14	Has your participation in any private, federal or state health insurance program been terminated, non-renewed, denied, suspended, restricted, placed on probation, or are you the subject of a current investigation or proceeding by such entities?		
15	Have you surrendered your state or federal controlled substances permit or registration?		
16	Has your membership in a professional society been revoked, suspended, or disciplined or have you resigned membership while under investigation		
17	In the 10 years prior to this application have any malpractice claims been settled by you or on your behalf?		
18	Has any court determined you are currently in violation of a court’s judgment or order for the support of dependent children?		

OATH OR AFFIRMATION OF APPLICANT
I HEREBY swear or affirm that all statements made and information provided in or with this application are true, correct and complete; that I am the person named in the credentials herewith presented and that I am the original and lawful possessor of such documents; that the photograph submitted to LSBME is a true likeness of me and that it was taken within the last 60 days; that in consideration of the issuance to me of a license/certificate to practice in Louisiana, I swear that I shall observe, abide by and uphold the laws of the State of Louisiana governing my practice and that I shall abstain from unethical, deceptive and fraudulent methods of practice and from immoral, unprofessional and unethical conduct, and that I shall not associate professionally with nor become a partner or employee of any person who resorts to such practices. I hereby agree that the violation of this oath shall constitute cause sufficient for the revocation of said license/certificate and surrender of the rights and privileges accorded me there under.

Signed _____________________________________________________

Full Name

Subscribed and sworn to before me this _____day of ____________ YEAR________

________________________ My commission expires___________

NOTARY PUBLIC

Louisiana State Board of Medical Examiners

Statement of Legal Name
1. My name appears as follows on the following documents:

a.) Medical/Professional diploma:      

b.) Internship and residency certificate(s): (give name and location of hospitals):

     

c.) E.C.F.M.G. Certificate:      

d.) State License(s): (Identify State)      

e.) Specialty Board Certificate(s): (Identify Board)      

f.) Certificate of Naturalization, Declaration of Intention, Valid Visa: (Specify)      

2. I am also known as: (list all names under which you are known)      

My legal name and the name under which I will be known by the Louisiana State Board of Medical Examiners is: (if different from that which appears in No. 1a-1f above, a certified copy of your Marriage Certificate, Divorce Decree or Court Order must accompany this statement)

First:       Middle:       Last:       Suffix:      

I understand that the Louisiana State Board of Medical Examiners maintains all records in alphabetical order and that I will be listed alphabetically under my surname (last name) as stated in Item 1a of this Application.
_____________________________________________

Signature

Subscribed and sworn on this ________ day of ____________, in the year _______.
________________________________

Notary Public

________________________________

My Commission Expires

SEAL
Louisiana State Board of Medical Examiners


Third Party Authorization

I understand and acknowledge that the submission of an application to, as well as the acceptance or maintenance of, any license, permit, certificate and/or registration (hereinafter referred to as a "license") issued by the Louisiana State Board of Medical Examiners (the "Board") shall constitute and operate as a perpetual authorization by me to each educational institution at which I have matriculated, each state or federal agency to which I have applied for any license, permit, certificate and/or registration, each person, firm, corporation, clinic, office or institution by whom or with whom I have been employed in the practice of medicine or as an allied health professional, each physician or other health care practitioner whom I have consulted or seen for diagnosis or treatment and each professional organization or specialty board to which I have applied for membership, to disclose and release to the Board any and all information and documentation concerning me which the Board may deem material to the consideration of my initial application and during such period as I may hold or maintain a license. With respect to any such information or documentation, the submission of an application to or the acceptance or maintenance of a license from the Board shall equally constitute and operate as a consent by me to the disclosure and release of such information and documentation and as a waiver by me of any privilege or right of confidentiality which I would otherwise possess with respect thereto. By submitting an application or accepting or maintaining a license issued by the Board, I shall be deemed to have given my consent to submit to physical or mental examinations if, when and in the manner so directed by the Board and to have waived all objections as to the admissibility or disclosure of findings, reports or recommendations pertaining thereto on the grounds of privileges provided by law. I acknowledge that the expense of any such examination shall be borne by me. The submission of an application or the acceptance or maintenance of a license from the Board shall also constitute and operate as perpetual authorization and consent by me to the Board to disclose and release any information or documentation set forth in or submitted with my application, or which then or at any time thereafter may be obtained by the Board from other persons, firms, corporations, associations or governmental entities, to any person, firm, corporation, association or governmental entity having a lawful, legitimate and reasonable need therefore, including, without limitation, the medical and/or allied health professional licensing, permitting, certifying and/or registering authority of any state; the Federation of State Medical Boards of the United States; professional organizations, associations and societies; the American Medical Association and any component state, county or parish medical society, including but not limited to the Louisiana State Medical Society and component parish societies thereof; the American Osteopathic Association; the Louisiana Osteopathic Medical Association; the Federal Drug Enforcement Agency; the Louisiana Office of Narcotics and Dangerous Drugs, Office of Licensing and Registration, Department of Health and Hospitals; federal, state, county or parish and municipal health and law enforcement agencies and the Armed Services. I understand that this authorization and consent is valid commencing on the date herein below subscribed and that such will remain in force and effect until and unless I withdraw my application for, or no longer possess or maintain, a license issued by the Board. I also acknowledge that a duplicate of this document may serve as an original. Printed Name (Full Name):       Signature (Full Name): _____________________________________________ **TO BE SIGNED IN THE PRESENCE OF A NOTARY Subscribed and sworn to before me this ________________ day of ___________________________________, 20 __________. ___________________________________________________ Notary Public Seal My Commission expires: _______________________________

Louisiana State Board of Medical Examiners

MD/DO Applicant Checklist
DO NOT RETURN TO LSBME

1. 
   ____ LSBME application (2 pages)
   
2. 
   ____ Third party authorization for release of information (must be notarized)
   
3. 
   ____ Oath or Affirmation relating to professional background (must be notarized)
   
4. 
   ____ An affidavit for each “yes” answer in Oath or Affirmation (must be typed and notarized)
   
5. 
   ____ Statement of Legal Name
   
6. 
   ____ Application fee ($382.00) Check or Money Order ONLY - non refundable
   

Request separately

1. 
   ____ FCVS application
   
2. 
   ____ Use this page only if you took a licensing examination (State Board Exam, FLEX, USMLE, NBME, NBOME, COMLEX), certification or recertification examination more than 10 yrs prior to the date of this application.
   
3. 
   ____ Request for Criminal Background check