Healthcare Board of Medicine

Healthcare Board of Medicine — Application for Licensure

Applicant Information

Full legal name:

Date of birth:   Gender:

Professional Education and Training

Licensure, Malpractice and Disciplinary History

List all state medical licenses ever held (state, license number, issue date, status):

Have you ever been the subject of professional disciplinary action, investigation, or sanction by any licensing authority or professional body? Yes No

Have you ever been convicted of a felony or crime related to the practice of medicine? Yes No

Have any malpractice claims been filed against you in the past ten years? Yes No

Current Practice and Insurance

Attachments and Required Documentation

Check each document enclosed with this application:

Official medical school transcript

Residency training verification

Board certification documentation (if applicable)

Copies of previous state license verifications

Malpractice claim history documents (if applicable)

Government-issued photo ID photocopy

Legal Attestation and Authorization

I, the undersigned Applicant, certify under penalty of law that the information provided in this application and in all supporting documents is true, complete, and correct. I understand that any material misstatement or omission may be grounds for denial of licensure, disciplinary action, civil penalty, or criminal prosecution as provided by law.

I authorize the Healthcare Board of Medicine and its authorized agents to obtain and review background information, including but not limited to criminal history records, professional disciplinary records, and verification of education, training and licensure. I hereby authorize any person, institution, or agency to release such information to the Board upon request. This authorization will remain effective until the date indicated below as the expiration of authorization.

I acknowledge my continuing obligation to notify the Board in writing within thirty (30) days of any change in the information provided in this application, including any arrest, charge, conviction, disciplinary action, or malpractice claim arising after the date of this application.

Applicant certifies that all required fees have been submitted in accordance with Board fee schedule and that required supporting documentation accompanies this application. The Board may request additional information as necessary to complete its review.

Oath and Signature

I declare under penalty of perjury under the laws of this jurisdiction that the foregoing statements are true and correct. I understand that this application and supporting documents are public records and may be subject to disclosure pursuant to applicable law.

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