Physician (not using fcvs) Application Forms Check List

Physician (not using FCVS) Application Forms Check List
Below is a list of credentials that are required to obtain a license. You are responsible for requesting these documents. Some applicants may be required to submit additional documentation. If additional documentation is needed, your online status will be updated to reflect the items needed. Please print this page for your records.

ITEMS NEEDED	INSTRUCTIONS
Applicants Oath	Have form notarized and send to the NC Medical Board.
Name Change documentation	If you have ever had a name change, you will need to provide documentation. Example: Marriage certificate; divorce decree
NPDB/HIPDB Reports	Applicants must submit a National Practitioner Data Bank (NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB) report as part of their application. The NPDB and HIPDB report must be dated within sixty (60) days of submission of your application to the NCMB. You will need to send the notarized “self -query” form to the National Practitioner Data Bank address.  They will forward the report to you and you will need to send the report to the North Carolina Medical Board. The NPDB/HIPDB web site address is http://www.npdb-hipdb.hrsa.gov/welcomesq.html.
Malpractice Documents Plaintiff’s Complaint and Settlement Orders	You will need to submit the plaintiff’s complaint and settlement orders for each malpractice claim where you have been named.
Examination Scores	Must come directly to the NC Medical Board from the original source.
Medical School Certification	Send form to medical school for completion. Original form must be returned directly to the NC Medical Board from your medical school.
Medical School Transcripts	Transcripts are required if you attended more than 1 medical school or more or less than the standard 4 years.

ECFMG Certification Status Report	Graduates of foreign medical schools must have a current ECFMG. You will need to contact ECFMG (http://www.ecfmg.org/) and have a certification status report sent to the NC Medical Board This report can be sent to us electronically from ECFMG.
5^th Pathway	Graduates of a foreign medical school, who have completed a Fifth Pathway program, must furnish verification of passing the ECFMG examination and completion of the 5^th Pathway Program. You will need to contact ECFMG (http://www.ecfmg.org) and have your score transcript forwarded directly to the NC Medical Board. You can obtain a Fifth Pathway Verification Form, by e-mailing our office at [e-mail]. You will need to forward this form to your Fifth Pathway program for completion. This form must be sent directly from the program to the NC Medical Board.
Physician Recommendation Forms	Two recommendations must be from physicians using the physician Reference Forms. Recommendations cannot be from a relative. These forms must be sent from the reference source directly to the NC Medical Board.
AMA Profile	Applicants must request an AMA Physician Profile from the AMA. Visit the AMA’s web site (https://profiles.ama-assn.org/amaprofiles) to request a profile be mailed directly to the NCMB office from the AMA.
AOA Profile	If you are a DO, visit the American Osteopathic Association’s web site (https://www.doprofiles.org) to request a physician profile be sent directly to the NCMB from the AOA. This should be done in addition to the AMA profile.
Postgraduate Training Verification Forms	You must send a PGT verification form to each institution where you have participated in training. Forms must be sent directly to the NC Medical Board from the source.
State License Verifications	You must secure a report from each state and country regarding status of licensure. All licenses, active and/or inactive, must be verified. Most licensing agencies charge a fee for this service. The verifications should be sent directly to the NC medical Board. Most states charge a fee for license verifications. Veridoc is accepted by the NCMB.
Board Action Data Bank Form	Complete form and send to the Federation of State Medical Boards. (http://www.fsmb.org/fpdc_data_inquiry.htmlThey will forward directly to the NCMB. You will not need to complete this form if you took Flex or USMLE.
Authority to Release Form	Sign and date form. Send original to the NC Medical Board.
Fingerprint Cards	Complete 2 fingerprint cards and return to the NC Medical Board along with the authority to release form.
Ten Year Rule Qualification	Documentation of one of the following must be accomplished within the past 10 years. 1 - USMLE examination 2 - National Osteopathic Board of Medical Examiners Examination or COMLEX. 3 - SPEX examination with a score of at least 75 4 - COMVEX examination – Osteopathic examination equivalent to SPEX. 5 - Certification or recertification by a specialty board recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). 6 - Certificate of Added Qualifications issued by a speciality board recognized by ABMS or AOA. 7 - Completion of formal ACGME or AOA post-graduate training You must provide this office with verification of one of the above. The SPEX requirement may be waived by the Board upon receipt of a current 3 year AMA Physician's Recognition Award or equivalent AOA CME. Visit the AMA’s web site for CME requirements. If the AMA/PRA is submitted to satisfy this requirement, copies of the CME documentation used to obtain the award must be included as part of your NC medical license application clearly showing the majority of the CME is relevant to your speciality or area of practice.

Revised: 4/09