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 www.mass.gov/massmedboard INITIAL LIMITED LICENSE INSTRUCTIONS INFORMATION Previous Medical License in Massachusetts: If you ever held a full license in Massachusetts, do not use this application form. A physician who holds or who has ever held a full Massachusetts license is not eligible for a limited license. Practice of Medicine: Please be advised that pursuant to Massachusetts laws and regulations, you may not engage in direct or indirect clinical care in a training program prior to the Board issuing a limited license. Both the Physician and the participating training program are responsible for determining that the Board has issued a limited license prior to the physician practicing medicine in Massachusetts. Licensing Process: 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. The application review process is defined by the Board of Registration in Medicine’s statutes, regulations and policies. The Board and its staff must comply with those requirements in processing applications. Applications are processed in the order in which they are received at the Board. An application will not be deemed complete and forwarded to the Board for its consideration until all required application documents and verifications are received and reviewed by Licensing Division staff. Grounds for Denial: As an applicant, you are personally responsible for all information disclosed on your license application, including any responses that may have been completed on your behalf by others. An application may be denied based upon omission, falsification or misrepresentation of any item or response on the application or any supplemental documentation received in connection with your application. The Massachusetts Board of Registration in Medicine considers violations of an ethical nature to be a serious breach of professional conduct. Each applicant’s qualifications for licensure in Massachusetts are reviewed on an individual basis. The Board has the authority to deny licensure based upon an applicant’s failure to meet the Board’s requirements for licensure; failure to provide satisfactory proof of good moral character; or because of acts which, were they engaged in by a licensee, would violate M.G.L. c. 112, Section 5 or 243 CMR 1.03(5). Interview: During the licensing process, you may be invited for a personal interview with the Board, and/or the Licensing Committee regarding your license application. Unless otherwise indicated, all meetings of the Board or any of its Committees are held at the Board office at 200 Harvard Mill Square, Suite 330, Wakefield, Massachusetts. IMPORTANT NOTES: Limited licenses are issued to physicians enrolled in postgraduate medical education programs in healthcare facilities in the Commonwealth of Massachusetts. All such training must be done in either an ACGME-accredited or AOA-approved program, or in a subspecialty clinical training or fellowship program in a training facility that has an approved program in the parent specialty. This information must be documented by the training program in Section B of this Limited License Application. You may practice medicine only in the training program approved with this application. Following Board approval of your limited license, your limited registration certificate verifying your registration number will be sent to your training program and they will provide you with a copy of the certificate. That license number will be retained for the duration of that training program. If you enter a different training program (for example, change from a residency in general surgery to a fellowship in plastic surgery) at the same facility or another training program, you must submit a Change of Program Application. A new license will be issued, assuming that you still qualify for limited license registration. Please be advised that your limited license expires at the end of the academic year or earlier if your training is completed before the end of the academic year. If you are continuing in a training program, a limited renewal application must be completed and submitted to the Board at least 30 days prior to the end of the academic year. The issuance of a limited license beyond a total of seven years of training may be granted only by a majority vote of the Board.
In addition to these required forms, you must submit to the Board a current updated curriculum vitae from the date of your graduation from medical school to the present by month and year (Example: December 2013 to July 2014). Other name(s): If you have any other names that may appear on your identifying documents, such as medical education and examination records, 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 Name Change form. Qualifying Examinations: Applicants for a limited license must have passing scores on USMLE Step 1 and Step 2 (CK and CS), or the first two levels of COMLEX, or all parts of MCCQE (LMCC).The Board will accept a copy of the USMLE scores, COMLEX, or MCCQE if they were part of the ERAS application that was sent directly from the original source to the training program. The exam report should be sent to the Board by the Graduate Medical Education staff with the initial limited license application. Otherwise, exam scores for USMLE may be obtained from the Federation of State Medical Boards (FSMB) at www.fsmb.org or the National Board of Osteopathic Medical Examiners for COMLEX at www.nbome.org or the Medical Council of Canada at www.mcc.ca for the MCCQE. NOTE: If you completed USMLE Step 2, CS or CK after the ERAS report was sent to your training program, you must request your USMLE scores from the FSMB to be sent to your training program.Examination scores from applicants will not be accepted unless they were sent to the applicant from the primary source in a sealed envelope. If your examination scores were not sent directly to your training program by ERAS, you then must request them in a sealed envelope and include them with your limited license application.Translations: Original translations must be provided for any documents in a language other than English. The Board will accept an English translation if it was translated by your medical school and has an original medical school seal. If a transcript is provided in a language other than English, you must obtain an official translation by a translation company in the United States or at a U.S. Embassy. An Official U.S. Translation Company is a private organization located in the U.S. engaged solely in the practice of translating documents and inter-language communication, e.g. Berlitz, Polylingua, Inc., etc. These companies can be located by looking under Translators and Interpreters on the internet. An office of a U.S. translation company located outside the U.S. is acceptable. English translations received directly from the Medical School Dean, with the seal of the medical school, will be accepted. APPLICATION INSTRUCTIONS1-B. Other name(s): If you used another name that appears on your identification documents, such as medical education and examination records, 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. 2. Current residence: Provide a mailing address and telephone number where you can be reached. You must immediately notify the Board of any change in this information. 5. Social Security Number: Your social security number may be used to facilitate the authorized sharing of information with designated agencies for identification of licensees for the following purposes: reporting of disciplinary actions to national data repository systems; tax default status; student loan default status; child support arrearages; Medicaid provider eligibility; possession of Massachusetts controlled substances registration; and collection of fines imposed in connection with Board disciplinary cases. The Board considers this information highly confidential and not subject to release except as specifically authorized. If you do not have a Social Security number, you must complete the Affidavit form and include it with your Initial Limited License Application. 6. Name and address of Massachusetts training hospital: This is the name of the healthcare facility at which you will be practicing with your initial limited license. This information should correspond with the information in Section B. 7. Name of premedical school(s): Supply the name of the school(s) at which you completed your undergraduate premedical education. If you are an international medical graduate and completed your premedical education at your medical school, please include the name of your medical school in this section. 9. Postgraduate Training: If you are either currently engaged in or previously engaged in postgraduate training in the U.S. or Canada, please respond affirmatively to Question 9 and answer Questions 9a – i. If you have not participated in any postgraduate training in the U.S. or Canada, please respond negatively to Question 9 and go on to Question 10. 11. Examinations completed: Indicate all licensing examinations which you have completed. Please provide supporting evidence of these examinations by accessing the Federation of State Medical Board’s (FSMB) on-line services to request your USMLE scores in a sealed envelope. The Board will accept a copy of the USMLE scores, COMLEX, or MCCQE if they were part of the ERAS application that was sent electronically to the training program. Otherwise, you must request the examination scores to be sent to you in a sealed envelope. 12. MassHealth Enrollment: Physicians (including interns and residents) are eligible to order, refer or prescribe services for MassHealth members and, under state law, must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure. MassHealth has created a Nonbilling Provider Application for providers in provider types that are not eligible to enroll as fully participating providers. This application can also be used by providers who are eligible to enroll in MassHealth as fully participating providers but who choose not to at this time. Physicians must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure. Providers who are already enrolled with MassHealth have already met the requirement and do not need to take further action. Providers who wish to apply to enroll as nonbilling providers must download the materials from the MassHealth website at http://www.mass.gov/eohhs/docs/masshealth/aca/pe-nbp-con.pdf and send their completed and signed Nonbilling Provider Application and Nonbilling Provider Contract by mail to the MassHealth Customer Service Center at: MassHealth Customer Service Center Attn: Provider Enrollment and Credentialing P.O. Box 121205 Boston, MA 02112-1205 Providers who have questions should contact the MassHealth Customer Service Center at 1-800-841-2900. 13. Time between graduation and start of training: If you answer affirmatively to Question 13, provide a chronological listing by month and year of all activities since graduation from medical school. This would include all postgraduate training, research activities, hospital affiliations, medical staff appointments, faculty appointments, private practices, military assignments, locum tenens and telemedicine assignments and any other employment or volunteer activities. Also include periods of unemployment or any activities outside of the practice of medicine. You must account for any time gaps of 30 days or more since your graduation from medical school. Failure to address any time gaps may result in delay of licensure. SECTION B must be completed and signed by the designated official at the healthcare facility.
Initial Limited License Application Form: Complete Section A, as well as any other forms that apply, and forward the application to the training program for completion of Section B. Medical Education Verification Form: Pre-medical education must be certified by your medical school(s) on the Medical Education Verification form. You must have successfully completed a minimum of two (2) or more academic years at a legally chartered college or university. If you attended more than one medical school you must obtain verification from all medical schools. Do not open the envelope from your medical school and inform the members of your household not to open the envelope. If the seal on the envelope from your medical school is opened, the Medical School Verification form will not be accepted and you will be required to obtain a new Medical School Verification. This will delay the processing of your Limited License Application. Attendance: The first two (2) years of medical school is defined as physical presence at the program for matriculation. Attendance during the third and fourth years of medical school is defined as enrollment in clinical study at the degree-granting institution and as further described by the Board of Registration in Medicine’s regulations and under Medical Education Verification form above. Transfers: If you have transferred from one medical school to another, please request a letter from the medical school’s registrar’s office explaining the reason(s) for the transfer. The letter should be sent to you and included with the Limited License Application. If the seal on the envelope is opened, you will be required to obtain a new letter and your application will be delayed. International Medical Graduates: You may wish to send your Medical Education Verification form via an international carrier with a prepaid return envelope addressed to you and it must be included with your Initial Limited License application and other documents. If the Medical School Verification and transcripts are provided in a language other than English, you will be required to provide an official translation by a translation company in the United States or by a U.S.Embassy. Medical School Diploma: International medical graduates must include a U.S. notarized copy of the medical school diploma with an original medical school seal with the initial limited license application. If your medical school diploma is not written in English, you must have it translated and notarized by a U.S. translation company or a U.S. Embassy. The medical school verification and all documents must be sent to you in sealed envelopes. If the seal is opened, you will be required to repeat the process. Please note: The Board of Registration in Medicine (Board) will not grant a limited license prior to the medical school awarding you an M.D. or D.O. degree. In the event that your medical school has determined that you have not met the requirements for graduation, you must notify the Board within 24 hours following notification by your medical school. Authorization for Release of Information: Sign and date the Authorization for Release of Information form and include it with your Initial Limited License Application. State License Verification: If you are currently licensed, or if you have ever held a full license in the United States, Puerto Rico, or Canada, you must submit state license verifications from the appropriate state boards. Please provide the state license verification in a sealed envelope and include it with your Initial Limited License Application. If the seal on the envelope from the state board is opened, the State License Verification will not be accepted by the Massachusetts Board and you will be required to repeat the process. The state boards of California, Texas, Indiana, Pennsylvania and the verification service, Veridoc, will only send license verifications directly to the Massachusetts Board of Registration in Medicine. Supervisory Evaluation Form: If this is your first postgraduate training program, you do not need to complete the Supervisory Evaluation Form. If you ever had any postgraduate training in another state, whether or not it was completed, the Supervisory Evaluation Form must be completed by the program director or the department chairman. If you were practicing medicine or had medical staff privileges, the Supervisory Evaluation Form must be completed by the department chairman, department chief or another person who supervised your clinical activity. The Supervisory Evaluation Form must be returned to you in a sealed envelope and included with your Initial Limited License Application. If the seal on the envelope is opened, it will be returned to you and then you will have to repeat the process. International Medical Graduates ECFMG Status Report: The ECFMG Status Report will be sent directly to the Board from ECFMG electronically. Go to https://cvsonline2.ecfmg.org/ImgGenInfo.asp for information and instructions on how to apply for your ECFMG status report. Substantial Equivalency of Medical School Education and Off-Site Clinical Clerkships: 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 elective clinical training, or any required clinical training of the (2) two-year clinical study requirement 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 Policy 91-003. The Waiver for Substantial Equivalency of Medical School education, Board Policy 91-003 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 limited 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 the following medical schools is substantially equivalent to U.S. medical school training. Graduates of the following medical schools DO NOT need to complete a Waiver Request or Forms E-1 and E-2:
Malpractice History Request Form (Only for applicants who held a full license in any state or who were named in a medical malpractice claim while in a postgraduate training program) Complete the Malpractice History Request Form listing all liability carriers from the time you completed your postgraduate training to the present. If you were enrolled in a postgraduate training program, 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.
Note: 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 liability carrier that took over in the merger or the Division of Insurance in the state where the liability carrier was registered. Criminal History (Only for applicants who responded affirmatively to Question #25) You must report being arrested, arraigned, indicted or convicted, even if the charges against you were dropped, filed, dismissed or otherwise discharged. A charge of operating under the influence or its equivalent is reportable. A medical malpractice claim is a civil, not a criminal, matter and need not be reported for purposes of this question. For each criminal proceeding in which you were named a defendant, certified copies of the complaint, 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. The sealed envelopes must be included with your full license application. You must also provide a detailed explanation of the incident, including date, time, place, the court action and final disposition. If in doubt as to whether an arrest or criminal offense must be disclosed, it is best to disclose the action on your application. Expunged/Sealed Offenses: While expunged offenses, arrests, tickets or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact been expunged or sealed. Failure to reveal an offense, arrest, ticket or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. You may have been told your record is expunged or sealed when in fact it is not. If, during the course of the application process, information about an offense is discovered which you did not disclose because you believed it to be expunged or sealed, you will be required to provide a copy of the expunction or sealing order. 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 medical board has terminated the probation. 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. Initial Limited Lic App (Instructions), Page of , Rev. 2/18 Yüklə 54,74 Kb. Dostları ilə paylaş:
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