Are you an active duty member of the United States …

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 Retired physicians who maintain an active license, but who have withdrawn from employment in any medically related field, as evidenced by an affidavit filed with NICA (a copy of this affidavit must be provided to the Department of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 1008, Revised 12/2020, Rule 64B8-4.009, F.A.C.

Page 3 of 24

Medical Doctor Application

for Limited 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

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. Refer to sections (s.) 459.0055 and 459.0075, Florida Statutes (F.S.) for eligibility requirements.

Medical Doctor Limited License (1506)

Select the option applicable to your proposed practice setting:

Compensated Practice (must be Fully Retired) $655.00 + NICA Fee

NICA Exempt: $0.00 - Total $655.00 (Submit proof of exemption) NICA Non-Participating: $250.00 - Total $905.00

NICA Participating: $5,000.00 - Total $5,655.00 Non-compensated Practice No Fee

Fully Retired

Not Fully Retired

Dispensing (Optional) + $100.00

(See description on page 3)

1. PERSONAL INFORMATION

Fee includes the following:

Application Fee (non-refundable) $300.00

Initial Licensure Fee

$350.00

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 to withdraw must be made in writing.

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 1008, Revised 12/2020, Rule 64B8-4.009, F.A.C.

Page 4 of 24

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 1008, Revised 12/2020, Rule 64B8-4.009, F.A.C.

Page 5 of 24

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