FLORIDA BOARD OF MEDICINE MEDICAL DOCTOR …

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.

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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

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 the medical school transcript(s), medical school diploma, medical school verification, name change document(s), national examination score report, ECFMG certificate, ECFMG verification and postgraduate training verifications. 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 your postgraduate training).

Year: ________ YYYY

D. Do you hold, or have you ever held a license to practice medicine or any other regulated professional

license(s)?

Yes

No

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

Lniecceenssseary. Type

License #

State/Jurisdiction or Country

Original Date Issued

(MM/DD/YYYY)

Expiration Date

(MM/DD/YYYY)

Status of License

Submit a License Verification 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. Applicants educated outside the U.S. may be required to request international license verification(s). You will be notified in writing if international license verification is required.

F. Have you practiced medicine in any jurisdiction for two of the last four years, or completed a board approved

post-graduate training program within the last two years?

Yes

No

G. If you responded "No" to F, have you passed a board-approved clinical competency exam within the last

year? Yes

No

If "Yes" to G, request supporting documentation.

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 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.

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5. EDUCATION / TRAINING HISTORY

Name: _____________________________________________

A. Have you completed the equivalent of two academic years of preprofessional, postsecondary education

including courses in anatomy, biology and chemistry prior to entering medical school? Yes

No

B. List in chronological order all medical schools attended, whether completed or not. Attach a separate sheet if

necessary.

Dates of Attendance: Date Degree

School Name

School Address

From-To

Received

(MM/DD/YYYY)

(MM/DD/YYYY)

to

to

to

to

All applicants except those using FCVS must have the "Medical Degree Verification" form (found at the back of the application) submitted directly to the board office from the school from which they received their medical degree. Any information not verifiable by FCVS may require the applicant to submit it.

C. Are you currently certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?

Yes

No

All applicants who are certified by the ECFMG except those using FCVS must have ECFMG Certification Status Report submitted to the board office directly from the ECFMG. Contact ECFMG Applicant Information Services at:

ECFMG 3624 Market Street Philadelphia, PA 19104-2685 USA Phone: (215) 386-5900 (Mon-Fri, 9:00 AM to 5:00 PM EST) Fax: (215) 386-9196

Include your USMLE/ECFMG Identification Number, if one has been assigned, when communicating with ECFMG.

D. List in chronological order from date of graduation from medical school to the present all postgraduate training (internship/residency/fellowship). List all programs you began, whether or not you completed or received credit for the training.

Program Name/Address

Specialty Area

Dates of Attendance: From-To

(MM/DD/YYYY)

Credit Received?

to

Y N

to

Y N

to

Y N

All applicants except those using FCVS must have the "Postgraduate Training Verification" form (found at the back of the application) submitted directly to the board office from the Chairman/Director of each postgraduate training program attended, whether completed or not. Any information not verifiable by FCVS may require the applicant to submit it.

E. Are you certified by any specialty board recognized by the American Board of Medical Specialties or specialty

board approved by the Florida Board of Medicine?

Yes

No

If you responded "Yes," complete the following:

Board Name

Certification/Specialty/Subspecialty

Date of Certification (MM/YYYY)

DH-MQA 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.

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Name: _____________________________________________

6. FIFTH PATHWAY CERTIFICATE HOLDERS ONLY Answer the questions in this section only if you hold a Fifth Pathway Certificate.

A. Did you attend an international medical school and do not possess a valid ECFMG Certificate? Yes No

B. Did you receive a bachelor's degree from an accredited United States college or University? Yes

No

C. Did you study at a medical school which is recognized by the World Health Organization? Yes

No

D. Did you complete all of the formal requirement of the International medical school, except the internship or social

service requirements, and pass Part I of the National Board of Medical Examiners or the Educational

Commission for Foreign Medical Graduates Examination equivalent?

Yes

No

E. Did you complete an academic year of supervised clinical training in a hospital affiliated with a medical school

approved by the Council on Medical Education of the American Medical Association and upon completion

passed Part II of the National Board of Medical Examiners examination or the Educational Commission for

Foreign Medical Graduates examination equivalent?

Yes

No

If you responded "Yes" to any of the questions in this section, you must request verifications be sent to the board office directly from the appropriate entity.

All Fifth Pathway Certificate holders must submit the following:

Verification of your Fifth Pathway program

Verification of NBME I & II examination, USMLE or ECFMG examination equivalent score reports

7. EXAMINATION HISTORY

Select from the following which exam(s) you have passed:

State Board (prior to 1974)

State Board (after 1974) and SPEX

LMCC and SPEX

National Examination (NBME, FLEX, or USMLE III)

Combination (prior to 2000)- View for more information.

Exam Taken

Exam Date (MM/DD/YYYY)

All applicants except those using FCVS must request all examination score reports to be submitted to the board office directly from the score reporting entity. The applicant is responsible for any associated fees to furnish this information. Use the following information to contact the appropriate reporting entity.

National Board score report National Board of Medical Examiners Inc. 3750 Market Street Philadelphia, PA 19104-3190 (215)590-9500

SPEX, FLEX, or USMLE score report Federation of State Medical Boards 400 Fuller Wiser Rd., Suite 300 Euless, TX 76039-3855 (817)868-4000

DH-MQA 1000, Revised 12/2020, Rule 64B8-4.009, F.A.C.

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