Previous Medical License in Massachusetts: If you ever held a full license in Massachusetts, do not use this application form
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Board of Registration in Medicine 200 Harvard Mill Square, Suite 330 Wakefield, MA 01880 Telephone: (781) 876-8210 Fax: (781) 876-8383 FULL, ADMINSTRATIVE AND VOLUNTEER LICENSE APPLICATION INSTRUCTIONS TABLE OF CONTENTS GENERAL INFORMATION 2 DOCUMENTS TO BE SUBMITTED WITH YOUR APPLICATION 2 FULL, ADMINSTRATIVE AND VOLUNTEER LICENSE INSTRUCTIONS 3 OPIOID AND PAIN MANAGEMENT TRAINING 4 TRAINING TO RECOGNIZE AND REPORT SUSPECTED CHILD ABUSE OR NEGLECT 5 MORAL AND PROFESSIONAL CHARACTER 5 POSTGRADUATE TRAINING VERIFICATION 6 EVALUATION FORM 6 STATE LICENSE VERIFICATIONS 6 NATIONAL PRACTITIONER DATA BANK 6 MEDICAL EDUCATION VERIFICATION 7 EXAMINATION REQUIREMENTS 7 NBME DIPLOMATE CERTIFICATION 8 NBOME DIPLOMATE CERTIFICATION 8 LMCC 8 FLEX/STATE EXAMINATION 8 AMA PHYSICIAN PROFILE 8 OSTEOPATHIC PHYSICIAN PROFILE 8 ECFMG STATUS REPORT 8 SUBSTANTIAL EQUIVALENCY AND OFF SITE ROTATIONS 8 MALPRACTICE HISTORY FORM 9 CRIMINAL HISTORY 9 CRIMINAL OFFENDER RECORD INFORMATION (CORI) 10 FEDERATION CREDENTIALS VERIFICATION PROFILE (FCVS) 10 TELEPHONE DIRECTORY & WEBSITE ADDRESSES 11
1. Full License Application – every data field on the full license application must be completed 2. Curriculum vitae 3. Supplement – all questions answered and supplement pages completed for any “ yes” answers 4. Authorization for Release 5. CORI Acknowledgment Form 6. Electronic Health Records (EHR) Proficiency Form 7. 90-Day Form 8. Certificate of Moral and Professional Character (sealed envelope) 9. State License Verifications (sealed envelopes) 10. Evaluations (sealed envelopes) 11. Postgraduate Verifications (sealed envelopes) 12. Examination scores (sealed envelope) 13. National Practitioner Data Bank (sealed envelope) 14. Malpractice History Form – listing all liability carriers since postgraduate training 15. Malpractice history reports from all carriers since postgraduate training 16. ECFMG Certificate, notarized copy (international medical graduates only) 17. Medical School Diploma, notarized copy (international medical graduates only) 18. Legal documents, as required FULL, ADMINSTRATIVE AND VOLUNTEER LICENSE INSTRUCTIONS The Full License Application Kit consists of the forms required for completing the application process. You may download additional forms at the Board’s website at www.mass.gov/massmedboard. Throughout this application:
Instructions for Completing the Full License Application
Application Fee The application processing fee for a full license is $600.00 and is non-refundable. Please make your check payable to the Commonwealth of Massachusetts. A certified check or money order is preferred, but personal checks are accepted. License Type Select one of the following license types listed on the full license application.
Other Name(s) If you have had a name change, you must submit a notarized copy of your marriage certificate or a notarized copy of the court order changing your name. Please complete the Name Change and Duplicate License form and the Notary Public Attestation for the Name Change form. Social Security Number Each applicant is required to provide the Board with a United States Social Security Number pursuant to M.G.L. c. 30A, §13A. Mailing Address The Board will use your mailing address for all correspondence with you. Premedical Education A minimum of two (2) or more academic years at a legally-chartered college or university is required. Medical Education Four (4) academic years of instruction of not less than thirty-two (32) weeks in each academic year or courses which in the opinion of the Board of Registration in Medicine are equivalent, in a legally chartered medical school that grants the degree of doctor of medicine or its equivalent. Qualifying Examinations Please list all the licensing examinations you have completed. Postgraduate Training
Other State Licenses List all states where you ever had a full license, whether the license is active, inactive or not renewed. Opioid and Pain Management Training Physicians who prescribe controlled substances (Schedules II - VI), must have completed at least three (3) credits of Board-approved continuing professional development in effective pain management. Physicians are responsible for determining whether the pain management continuing professional development requirement applies to them, based upon the nature of their practice. A free online resource to obtain the necessary credits is available at www.opioidprescribing.com. Requirement to Complete Training to Recognize and Report Suspected Child Abuse or Neglect M.G.L. c. 119, §51A(k) requires all mandated reporters, professionally licensed by the Commonwealth, to complete training to recognize and report suspected child abuse or neglect. Physicians are one category of mandated reporters. Physicians may comply with the training requirement through:
Full license applicants must complete the requirement for training prior to submission of an application to the Board. This is a one-time requirement. Electronic Health Records (EHR) Proficiency Form This is a one-time requirement. Complete Section 1 (Demonstrating Proficiency) or Section 2 (Claiming an Exemption). Sign and date the form. Authorization for Release of Information Sign and date the Authorization for Release of Information form. Full Application Supplement Every question on the Full Application Supplement must be answered “yes” or “no.” If a question is answered “yes” you must provide an explanation in the supplement section for that question and provide the additional documents in sealed envelopes. You will be requesting the following documents to be sent directly to you in sealed envelopes Please request the signature of the endorser or seal of the institution to be placed across the back flap of the envelope. The National Practitioner Data Bank Profile and the USMLE will not have a seal or signature. Certificate of Moral and Professional Character The Certificate of Moral and Professional Character must be completed and signed by a physician who has a current medical license in the United States. The designated physician must not be the applicant’s relative but should have known the applicant for at least one (1) year. The form must be notarized by a U.S. notary. Postgraduate Training Verification Form Submit the Postgraduate Verification form to all health care facilities in the U.S., Puerto Rico or Canada where you have participated in any internship, residency or fellowship training, including training programs that were not completed. Note: If you are currently enrolled in a postgraduate training program, please do not have your postgraduate verification form signed by your program director until you have completed two (2) years of postgraduate training for U.S. graduates and three (3) years for international medical graduates. Evaluation Form At least one (1) year of current evaluations are required. The Board’s Evaluation form must be completed by a supervising physician, a training program director, department chairperson or a current or former supervising physician who can evaluate your clinical performance. Physicians who are not affiliated with a healthcare facility must obtain reference letters from three physicians who refer patients to them for clinical care. Locum tenens physicians must have Evaluation forms completed for the most recent two (2) years by health care facilities where you have had locum tenens assignments. Note: Evaluation forms must be current within 120 days prior to Board review. If there are any outstanding legal issues relating to your application, the evaluation must be completed within sixty (60) days of Board review. The Board reserves the right to require that Evaluation forms be current within thirty (30) days of Board review. State License Verifications You must obtain a written verification of every full license issued to you in the U.S., Puerto Rico or Canada in support of your full license application. The state boards of California, Texas, Indiana, Pennsylvania and Veridoc will only send license verifications directly to the Massachusetts Board of Registration in Medicine. The license verifications will be held in a pending file until your completed full license application is ready to be processed. National Practitioner Data Bank Profile License applicants must request a self-query profile from the National Practitioner Data Bank (NPDB). You may access the NPDB at www.npdb-hipdb.hrsa.gov and complete the self-query form online. After completing the self-query form, you will be required to verify your identity. In most cases this is an electronic process. If you are unable or unwilling to verify your identity electronically, you must verify your identity offline. The offline process requires you to print out a hard copy of your self-query form, have it notarized and forward it to the Data Bank. Please note that the NPDB will offer you a pdf and a paper copy of your NPDB profile. You must request a paper copy of your NPDB profile in addition to the pdf. The self-query fee of $5.00 is payable by credit card (VISA, MasterCard, American Express and Discover) or debit card (with VISA or MasterCard logo on the card). Please remember to include your credit or debit card number and expiration date on your query form. Once your identity is verified, the Data Bank will process your self-query request. When you profile is available, you will receive an email notification and instructions to view your profile online. In addition to the online profile, you will receive a paper copy of your profile by U.S. mail. When you receive the paper copy of your NPDB profile, DO NOT OPEN THE ENVELOPE. You must mail it directly to the Board with your license application. If the envelope is opened, it will be returned to you and a new profile request must be submitted. The NPDB requires up to four weeks to process a new profile. If you have questions, contact the Data Bank at 1-800-767-6732. Medical Education Verification Complete the authorization statement at the top of the Medical Education Verification form and send it to your medical school. If more than one medical school was attended, the form must be duplicated and sent to each additional school. If there were gaps in your medical education, or more than four (4) years of medical school for U.S graduates, or more than six (6) years for international medical school graduates, you must provide an explanation for the additional months or years and the medical school must also provide the dates and reason(s) for the additional months or years. International medical schools must provide a copy of the medical school transcripts in English. If the transcripts are in a language other than English, the Board will send a copy of the medical school transcripts to you to be translated either by your medical school or a U.S. translation company. Note: If you were ever issued a limited license in Massachusetts, your medical school verification is on file at the Board and you do not need to provide the medical education verification. Medical School Diploma International medical school graduates must provide a notarized copy of their medical school diploma with the full license application. The notarization must be completed b y a U.S. notary and, if it is not in English, it must be translated by a U.S. translation company. Transfer from Ph.D. or Dental School Program to an M.D. Program Transfer students who received credit from a Ph.D. or dental school program must submit the Medical Education Verification form with the official transcripts from the Ph.D. or dental school program. A letter of matriculation must also be sent to the Board from the medical school. Examination Requirements - USMLE and FLEX Contact the Federation of State Medical Boards (FSMB) at www.fsmb.org to request USMLE and FLEX scores. Please note that the Board’s regulations require that the USMLE Steps 1, 2 and 3 must be completed within a seven (7) year time period, beginning with the examination date when the examinee first passes his/her first Step (either Step 1 or Step 2). The Board may grant a waiver of the seven-year examination completion requirement in the case of an applicant who is actively pursuing another advanced doctoral study. In addition, in very limited and extraordinary circumstances, the Board may grant a case-by-case exception to the seven-year period upon petition by the applicant and demonstration by the applicant of: a. a verifiable and rational explanation for the failure to satisfy the regulation; b. strong academic and post-graduate record; and c. a compelling totality of circumstances. Please review the Board’s regulation 243 CMR 2.02(3) (b) and (c) for additional information. An applicant who fails to pass Step 3 of the USMLE or level 3 of the COMLEX within three (3) attempts is required to take an additional year of ACGME or AOA approved postgraduate training prior to attempting the step a fourth time. National Board of Medical Examiners Diplomate Certification Contact the National Board of Medical Examiners (NBME) at www.nbme.org to obtain the Endorsement of NBME Certification and under Programs and Services, select “NBME certification and transcripts” and follow the instructions to request examination scores. National Board of Osteopathic Medical Examiners Diplomate Certification You may access the National Board of Osteopathic Medical Examiners (NBOME) website at www.nbome.org for a transcript request form and instructions. LMCC Applicants providing LMCC results may request a transcript of LMCC Scores by fax at (613) 521- 9417 or send a letter to: The Registrar, Medical Council of Canada, Box 8234, 1867 Alta Vista Drive, Ottawa, KIG 3H7 Canada. A notarized copy of your LMCC Certificate must be sent to the Board with your Full License application. FLEX Examination/State Board Examination Verification Verification of a FLEX/State Examination must include the examination dates and scores. Massachusetts requires a FLEX passing score of 75 in each component. For examinations prior to June 1985, a FLEX weighted average score of 75 is required in one sitting. A state Board examination taken after June 19, 1970 will not be accepted for licensure. AMA Physician Profile The AMA Physician Profile may be requested online at www.ama-assn.org/AMAProfiles, or you may contact the AMA Customer Service for ordering assistance at (800) 665-2882 or (312) 364-5199. The AMA Physician Profile will be sent electronically directly to the Board. Osteopathic (D.O.) Physician Profile The Official Osteopathic Physician Report may be requested at www.osteopathic.org or at the American Osteopathic Information Association Credentials Services, 142 E. Ontario St., Chicago, IL 60611. Education Commission for Foreign Medical Graduates (ECFMG) Status Report An ECFMG Status Report may be requested at https://cvsonline2.ecfmg.org/ImgGenInfo.asp. The ECFMG Status Report will be sent electronically to the Board. Substantial Equivalency of Medical School Education and Off-Site Rotations: In situations where an international medical graduate cannot comply with 243 CMR 2.03(1)(b), requiring substantial equivalency of medical school education, a Waiver Request may be submitted to the Board. If an applicant completed more than three (3) months of any required or elective clinical rotation outside of the primary teaching hospital of their medical school of attendance, a Waiver Request (Form J) and Forms E-1 and E-2 are required. You must send a copy of Form E-1 to your medical school and Form E-2 must be forwarded to the program director at the program where you completed each clinical clerkship. E-2’s must be returned directly to the applicant in a sealed envelope. The Board will review the applicant’s medical school training and/or off-site clinical rotations to determine whether they are substantially equivalent to U.S. medical school training. In assessing the applicant’s equivalency of medical education, the Board relies on the factors detailed in Board Policy 91-001. The Waiver for Substantial Equivalency of Medical School education, Board Policy 91-001 and the E-1 and E-2 forms are available at the Board’s website. Requesting a waiver for substantial equivalency of medical school education may result in a delay in processing your full license, as determinations on waiver requests are made by the Board on a case-by-case basis. Please note: The Board has determined that the medical education at St. George’s University School of Medicine, SABA University, Ross University School of Medicine and the American University of the Caribbean is substantially equivalent to U.S. medical school training. Graduates of St. George’s University School of Medicine, SABA University, Ross University School of Medicine and the American University of the Caribbean do not have to complete a Waiver Request or Forms E-1 and E-2. Important Note: Following the submission of your application for licensure, the Board may, at any time, request additional documentation to determine the applicant’s compliance with the Board’s statutes and regulations. Applicants who are not in compliance with the Board of Registration in Medicine’s statutes and regulations may not be eligible for licensure. Malpractice History Form Complete the malpractice history form listing all liability carriers from the time you completed your postgraduate training to the present. Include the liability carrier for the time period when you were in a postgraduate training program only if you had a full license OR you were named in a malpractice case during that period.
If a malpractice history report is unavailable from the liability carrier due to merger or if the carrier is no longer in business, you must obtain a letter confirming the merger or closure from the Division of Insurance in the state where the liability carrier was registered. Criminal History For each criminal proceeding in which you were named a defendant, certified copies of the com plaint, judgment or other disposition and a copy of the police report must be sent to you in sealed envelopes from your lawyer, the court or other appropriate agency. You must also provide a detailed explanation of the incident, including date, time, place, who was with you and the court action. The sealed envelopes must be included with your full license application. Current Probation Agreement in Another State It is the practice of the Licensing Committee, a committee of the Board of Registration in Medicine, to defer action on applications from individuals with a current probation agreement in another state, until that state’s licensing board has terminated the probation. Criminal Offender Record Information (CORI) Criminal Offender Record Information (“CORI”) is part of a general background check for licensing purposes. In order to complete this background check, applicants must submit a notarized CORI Acknowledgment Form. You must sign your name in the presence of a U.S. Notary Public. It is preferred that, for purposes of identification, applicants submit identification issued by the U.S. government (i.e., driver’s license, identification card, etc.) If you do not have any identification issued by the U.S. government, an international passport may be used to verify the information on the CORI Acknowledgment Form. In completing the CORI Acknowledgment Form, you will need to provide the following required information: Last Name; First Name; Date of Birth; Last 6 digits of your Social Security Number (“SSN”). If you do not have an SSN, then you must enter 6 zeros – zeros may only be used for CORI if you do not have a valid SSN. An applicant who has a valid SSN and submits a CORI with zeros for a SSN can be subject to civil and criminal penalties. FCVS Physician Profile The Massachusetts Board of Registration in Medicine accepts the FCVS (Federation Credentials Verification Services) for verification of core credentials which includes medical school (from primary source) postgraduate training, examination scores and ECFMG verification. If you choose to utilize FCVS, you m ay obtain information at www.fsmb.org or contact the FCVS at (817) 868-5000 or (888) 275-3287. The FCVS does not verify medical licenses in other states. Applicants utilizing FCVS for their core documents must also complete the following additional Board forms in accordance with the Board’s application instructions:
Copy your full application and supplement. You will be required to provide a copy to every health care facility for credentialing and for enrollment in health plans. TELEPHONE DIRECTORY AND WEBSITE ADDRESSES American Medical Association (800) 621-8335 www.ama-assn.org Board of Registration in Medicine (781) 876-8200 www.mass.gov/massmedboard Education Commission for Foreign Medical Graduates (ECFMG) (215) 386-5900 www.ecfmg.org Federal Drug Enforcement Administration (DEA) (617) 557-2468 www.deadiversion.usdoj.gov Federation of State Medical Boards (FSMB) (817) 868-4000 www.fsmb.org Massachusetts Department of Public Health--Controlled Substance License (617) 753-8052 Massachusetts Medical Society (781) 893-4610 www.massmed.org National Board of Medical Examiners (NBME) (215) 590-9500 www.nbme.org National Board of Osteopathic Medical Examiners (NBOME) (773) 714-0622 www.nbome.org National Practitioner Data Bank (NPDB) (800) 767-6732 www.npdb-hipdb.hrsa.gov Full Lic App (Instructions), Page of , Rev. 8/16 Yüklə 75,4 Kb. Dostları ilə paylaş:
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