Medical Doctor App - Florida Board of Medicine- Healthcare Practitioner ...
A R ME D
FORCES
LICENSING
Are you an active duty member of the United States Armed Services? Are you a veteran of the United States Armed Services?
Are you the spouse of a veteran of the United States Armed Services? Are you the spouse of an active member of the United States Armed Services? If you answered "Yes" to any of these questions, you may qualify for a reduction in Health's commitment to serving members and veterans of the United States Armed
Forces and their families online at
Important Qualification Information
All applicants must meet one of the following requirements:
Be a graduate of an Allopathic U.S. Medical School recognized and approved by the U.S. Office of Education and completed at least one year of approved residency training; OR
Be a graduate of an allopathic international medical school (IMG) and have a valid Educational Commission for Foreign Medical Graduates (ECFMG) certificate and completed an approved residency of at least two years in one specialty area; OR
Be a graduate who has completed the formal requirements of an international medical school except the internship or social service requirement, passed Parts I and II of the NBME or ECFMG equivalent examination, and completed an academic year of supervised clinical training (Fifth Pathway) and completed an approved residency of at least two years in one specialty area.
Licensure by Examination applicants must meet one of the following additional requirements:
Passed all parts of a United States national examination (NBME, FLEX, or USMLE); OR
Currently licensed in the U.S. or Canada, and has actively practiced pursuant to such licensure for at least ten years, has passed a state board or LMCC examination, and passed the SPEX examination; OR
Licensed on the basis of a state board exam prior to 1974, and is currently licensed in at least three other jurisdictions in the U.S. or Canada, and practiced pursuant to such licensure for at least 20 years
Visit section 458.311, Florida Statutes, for more information on applying by examination.
Licensure by Endorsement applicants must meet the following additional requirements:
Passed all parts of a United States national examination (NBME, FLEX, or USMLE) AND one of the following:
Licensed in another jurisdiction and actively practiced medicine in another jurisdiction for at least two of the immediately preceding four years; OR
Passed a board-approved clinical competency examination within the year preceding filing of the application; OR
Successfully completed a board approved postgraduate training program within two years preceding filing of the application.
Visit section 458.313, Florida Statutes, for more information on applying by endorsement.
Florida Birth Related Neurological Injury Compensation Association (NICA) Fund
All physicians licensed in Florida are required to pay into the NICA fund unless qualified for exemption. Visit for information on NICA participating, non-participating, and exempt. "Participating," is for Florida licensed physicians who practice obstetrics or perform obstetrical services on a full or part-time basis and do not meet any of the exemption criteria. "Non-participating," is for Florida licensed physicians who do not practice obstetrics or perform obstetrical services and do not meet any of the exemption criteria. To determine if you qualify for exemption review the exemptions listed on page 24 of this application or visit the NICA website listed above.
Dispensing Practitioner Information
"Dispensing" is defined as the transfer of possession of medicinal drugs from a physician to a patient in the office. A practitioner who writes prescriptions or provides medicinal drugs labeled as "drug sample" or "complimentary drug" is not a "dispensing practitioner," and therefore does not need to register with the department.
DH-MQA 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.
Page 3 of 27
Medical Doctor
Application for Licensure
Board of Medicine P.O. Box 6330
Tallahassee, FL 32314-6330 Fax: (850) 488-0596
Email: BOM_InitialApps@
Do Not Write in this Space For Revenue Receipting Only
Select the application method for Medical Doctor (1501) Licensure:
Examination (1024)
Endorsement (1021)
Select the appropriate fee based on residency/fellowship status: Not in a residency/fellowship $705.00 + NICA fee
NICA Exempt: $0.00- Total $705.00 (Submit proof of exemption) NICA Non-Participating: $250.00- Total $955.00 NICA Participating: $5,000.00- Total $5,705.00 In a residency/fellowship $555.00 (NICA Exempt) (Training director must submit a letter verifying dates of training)
Dispensing* (Optional) + $100.00
see description on page 3
Total fee includes the following:
Application Fee (non-refundable)
$350.00
Initial License Fee
Non-resident: $350.00 Resident: $200.00
Unlicensed Activity Fee
$5.00
NICA Exempt Fee
$0.00
NICA Non-Participating Fee
$250.00
NICA Participating Fee
$5,000.00
Dispensing (optional)
$100.00
Fees must be paid in the form of a cashier's check or money order, made payable to the Department of Health. Requests for a refund must be made in writing. Fees are refundable for up to three years from the date of receipt.
1. PERSONAL INFORMATION
Name: ______________________________________________________________________ Date of Birth: _______________
Last/Surname
First
Middle
MM/DD/YYYY
Mailing Address: (The address where mail and your license should be sent)
___________________________________________________ _______ __________________________________
Street/P.O. Box
Apt. No. City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Home/Cell Telephone (Input without dashes)
Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website)
___________________________________________________ _______ __________________________________
Street
(Place of Employment)
Suite No. City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Work/Cell Telephone (Input without dashes)
EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
Gender: Male Female
Race:
Native Hawaiian or Pacific Islander American Indian or Alaska Native Two or More Races
Hispanic or Latino Black or African American
White Asian
Email Notification: To be notified of the status of your application by email, check the "Yes" box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the board office.
Yes
No Email Address: ____________________________________________________
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.
Applicants who do not currently have a practice address are required to update their online practitioner profile with a practice address when it is available.
DH-MQA 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.
Page 4 of 27
2. SOCIAL SECURITY DISCLOSURE
This information is exempt from public records disclosure.
Pursuant to Title 42 United States Code ? 666(a)(13), the department is required and authorized to collect Social Security numbers relating to applications for professional licensure. Additionally, section (s.) 456.013(1)(a), Florida Statutes (F.S.), authorizes the collection of Social Security numbers as part of the general licensing provisions.
Last Name: _____________________________________________________________
First Name: _____________________________________________________________
Middle Name: ___________________________________________________________
Social Security Number: __________________________________________________
(Input without dashes)
Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code ? 653 and 654; and s. 456.013(1), 409.2577, and 409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for license identification pursuant to Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317). Clarification of the SSA process may be reviewed at or by calling 1-800-772-1213.
DH-MQA 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.
Page 5 of 27
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