State of Florida Department of Health - Florida Board of ...

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

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 parttime 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.

"Exempt," to determine if you qualify for exemption review the exemptions listed below or visit the NICA website listed above.

1. Resident physicians, assistant resident physicians and interns in postgraduate training programs approved by the Board of Medicine (documentation of the dates of your program signed by the chair of your department must be provided to NICA).

2. Retired physicians who maintain an active license, but who have withdrawn from employment in any medically related field, as evidenced by an affidavit filed with NICA (a copy of this affidavit must be provided to the Department of Health).

3. Physicians who hold a limited license, as defined by chapter (ch.) 458, Florida Statutes (F.S.), who do not receive any compensation for medical services (an affidavit must be provided to NICA stating that no compensation is received for medical services).

4. Physicians employed full-time by the Veterans Administration whose practices are confined to Veterans Administration hospitals (a letter from your employer stating you are a full-time employee as well as an affidavit from you stating you are not engaged in the private practice of medicine must be provided to NICA).

5. Any licensed physician on active duty with the Armed Forces of the United States; (a letter from your commanding officer stating that you are on active duty in the Armed Forces as well as an affidavit from you stating you are not engaged in the private practice of medicine must be provided to NICA).

6. Physicians who are full-time state of Florida employees whose practice is confined to state owned correctional facilities, mental health or developmental services facilities, or the Department of Health or County Health Department (a letter from state government documenting your employment status as well as an affidavit from you stating you are not engaged in outside employment must be provided to NICA).

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 1029, Revised 11/2020, Rule 64B15-12.003, F.A.C.

Page 3 of 27

Osteopathic Physician

Application for Licensure

Board of Osteopathic Medicine P.O. Box 6330

Tallahassee, FL 32314-6330 Fax: (850) 412-2684

Email: info@

Do Not Write in this Space For Revenue Receipting Only

All physicians licensed in Florida are required to pay into the NICA fund unless qualified for exemption. See page 3 for information on NICA participating, non-participating, and exempt.

Osteopathic Physician (1901) $505.00 + NICA Fee Select the appropriate option:

NICA Exempt: $0.00 - Total $505.00 (Submit proof of exemption)

NICA Non-Participating: $250.00 - Total $755.00

NICA Participating: $5,000.00 - Total $5,505.00

Dispensing* (Optional) + $100.00 * see description on page 3 (Complete form at end)

Total fee includes the following:

Application Fee (non-refundable)

$200.00

Initial Licensure Fee (refundable)

$300.00

Unlicensed Activity Fee (refundable)

$5.00

NICA Fee Varies Between

$0.00-$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 to withdraw or 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.

DH-MQA 1029, Revised 11/2020, Rule 64B15-12.003, 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 1029, Revised 11/2020, Rule 64B15-12.003, F.A.C.

Page 5 of 27

Name: _____________________________________________

3. APPLICANT BACKGROUND

A. Are you using the Federation Credentials Verification Service (FCVS) to verify your core credentials? Yes No

FCVS is not a requirement for licensure. FCVS will primary source verify and provide a copy of osteopathic medical school transcript(s), name change document(s), and national exam score report. Using this service will expedite your application only if the FCVS packet was complete prior to this application. For more information about FCVS visit their website at fcvs/.

B. List any other name(s) by which you have been known in the past. Attach additional sheets if necessary. __________________________________________________________________________________________

C. List the year you legally began to practice medicine (may be the date you began postgraduate training) ______ YYYY

D. Has it been more than two years since you practiced osteopathic medicine in any jurisdiction? Yes No

If "Yes," list the year you last practiced osteopathic medicine. ______ YYYY

E. Do you hold, or have you ever held a license to practice osteopathic medicine or any professional license(s)?

Yes

No

F. List all professional licenses (active, inactive or lapsed). Attach additional sheets if necessary.

License Type

License #

State/Jurisdiction or Country

Original Date

Expiration

Issued

Date

(MM/DD/YYYY) (MM/DD/YYYY)

Status of License

Submit a "License Verification Request" form to ALL state(s) of licensure. License verifications must be received directly from the licensing authority or regardless of the status of the license. Check for states that use the online verification service.

G. Are you registered with the DEA to prescribe controlled substances? Yes

No

H. If you have ever served in the United States (U.S.) Military or Public Health Service (PHS), have you ever been

disciplined by any branch of the U.S. Military or PHS? Yes No

N/A

If "Yes," provide the following:

A self-explanation on a separate sheet providing accurate details (including, but not limited to, the date(s), location(s), and specific circumstances).

Documentation from the U.S. Military/PHS regarding the disciplinary action and charge(s)/event(s).

4. DISASTER

Would you be willing to provide health services in special needs shelters or to help staff disaster medical assistance

teams during times of emergency or major disaster?

Yes

No

DH-MQA 1029, Revised 11/2020, Rule 64B15-12.003, F.A.C.

Page 6 of 27

Name: _____________________________________________

5. EDUCATION/TRAINING HISTORY

A. List the osteopathic medical school you attended. School Name/Address

Dates of Attendance: From-To (MM/DD/YYYY)

to

All applicants must have an official transcript forwarded directly to the board office from your osteopathic medical school. Diplomas and student copies are not acceptable. Transcripts should be sent to:

Board of Osteopathic Medicine 4052 Bald Cypress Way Bin C-06

Tallahassee, FL 32399-3257

B. List in chronological order from date of graduation from osteopathic medical school to the present all postgraduate training (internship/residency/fellowship). Attach additional sheets if necessary.

Program Name/Location

Program Type

AOA* or Dates of Attendance:

Specialty Area ACGME*

From-To

Approved

(MM/DD/YYYY)

Credit Received

Y N

to

Y

N

Y N

to

Y

N

Y N

to

Y

N

* AOA- American Osteopathic Association; ACGME- Accreditation Council for Graduate Medical Education

All applicants must provide the "Postgraduate Training Evaluation" form, found at the back of the application, for each program whether completed or not.

C. Are you certified by any specialty board recognized by the AOA, American Board of Medical Specialties

(ABMS), American Board of Interventional Pain Physicians (ABIPP), or American Association of Pharmaceutical

Scientists (AAPS)? Yes

No

If you responded "Yes," complete the following:

Board Name

Certification/Specialty/Subspecialty

Date of Certification (MM/DD/YYYY)

DH-MQA 1029, Revised 11/2020, Rule 64B15-12.003, F.A.C.

Page 7 of 27

Name: _____________________________________________

6. ACADEMIC FACULTY APPOINTMENTS / STAFF PRIVILEGES

A. Do you currently hold a faculty appointment at a medical school?

Yes No

B. Have you had the responsibility for graduate medical education within the last ten years? Yes No

If you responded "Yes" to A or B complete the following:

Name of Institution

Address

Title of Appointment

A "facility" is defined as a licensed hospital, health maintenance organization, pre-paid health clinic, ambulatory surgical center, or nursing home.

C. Do you currently hold staff privileges in any hospital, health institution, clinic, or medical facility (do not include

postgraduate training privileges)? Yes

No

If you responded "Yes," complete the following:

Name of Facility

Address

Type of Privileges

From-To (MM/DD/YYYY) to to

D. Have you ever had any staff privileges denied, suspended, revoked, modified, restricted, or placed on

probation, or have you been asked to resign to take a temporary leave of absence or otherwise acted against

by any facility?

Yes

No

If you responded "Yes," complete the following:

Name of Facility/Address

Action Date (MM/DD/YYYY)

Final Action

Under Appeal?

Y N

Y N

E. Have you ever been asked or allowed to resign from any facility in lieu of disciplinary action or during any

pending investigations into your practice?

Yes

No

If you responded "Yes," complete the following:

Name of Facility/Address

Action Date (MM/DD/YYYY)

Final Action

Under Appeal?

Y N

Y N

F. Have you ever had any staff privileges restricted or not renewed by any facility in lieu of disciplinary action? Yes No

If you responded "Yes," complete the following:

Name of Facility/Address

Action Date (MM/DD/YYYY)

Final Action

Under Appeal?

Y N

Y N

If you responded "Yes" to questions D, E, or F, provide the following:

A self-explanation on a separate sheet providing accurate details.

Supporting documents from the facility(ies).

DH-MQA 1029, Revised 11/2020, Rule 64B15-12.003, F.A.C.

Page 8 of 27

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