Fillable Instructions Forms & Instructions (Federation of State Medical Boards)

Fill Online, Printable, Fillable, Blank Instructions Forms & Instructions (Federation of State Medical Boards) Form

Use Fill to complete blank online FEDERATION OF STATE MEDICAL BOARDS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Instructions Forms & Instructions (Federation of State Medical Boards)

On average this form takes 55 minutes to complete

The Instructions Forms & Instructions (Federation of State Medical Boards) form is 33 pages long and contains:

  • 0 signatures
  • 51 check-boxes
  • 195 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Federation of State Medical Boards forms online.

BROWSE FEDERATION OF STATE MEDICAL BOARDS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
08-4675 Rev 12/1/2020 Instructions Page 2 of 10
Threshold Qualifications for Licensure
Permanent Medical License – United States Graduates:
o
Successful graduation from an AAMC- or AOA-accredited medical school.
o
Successful completion of post-graduate training in accredited programs in recognized hospitals:
o
If graduated from medical school prior to 01/01/1995 –1 year of postgraduate training.
o
If graduated from medical school on or after 01/01/1995 – 2 years of postgraduate training.
o
Successful passage of an acceptable licensing examination as defined by regulation.
o
Completion of an acceptable 2-hour education course in pain management and opioid use and addiction.
o
NOT have a license to practice medicine in another state, territory, province, or international licensing
jurisdiction
suspended or revoked or otherwise disciplined.
Permanent Medical License – International Graduates:
o Successful graduation from a medical school listed in the
World Directory of Medical schools.
o Successful completion of three (3) years of postgraduate training in accredited programs in recognized
hospitals in the United States or Canada.
o Completion of an acceptable 2-hour education course in pain management and opioid use and addiction.
o ECFMG Certificate.
o Successful passage of acceptable licensing examinations as defined by regulation.
o NOT have a license to practice medicine in another state, territory, or province suspended or revoked or
otherwise disciplined.
Podiatric Medicine License:
o
Successful graduation from a school of podiatry accredited by the Council of Podiatric Medical Education.
o
Successful completion of post-graduate training in a program accredited by the Council of Podiatric Medical
Education to include:
o
One year of internship training in podiatric medicine and;
o
One year of podiatric surgical training.
o
Completion of an acceptable 2-hour education course in pain management and opioid use and addiction.
o
Successful completion of the National Boards examination and the PMLexis examination.
Courtesy License:
o
Successful graduation from an AAMC- or AOA-accredited medical school if U.S. or Canadian graduate; if
any other international
medical school graduate, successful graduation from a school listed in the World
Health Organization directory of medical schools.
o
Successful completion of post-graduate training in accredited programs in recognized hospitals in the United
States or Canada.
o
Successful passage of an acceptable licensing examination as defined by regulation.
o
Active license in good standing (no disciplinary sanctions or restrictions) in state of residence; cannot be
under investigation.
o
Board certification in an American Board of Medical Specialties member board.
08-4675 Rev 12/1/2020 Instructions Page 3 of 10
Locum Tenens Permit – United States Graduates:
o
Successful graduation from an accredited medical school
o
Successful completion of post-graduate training in an accredited program in a recognized hospital:
o
1 Year – If graduated from medical school prior to 01/01/95
o
2 Years – If graduated from medical school 01/01/95 or later
o
Successful passage of an acceptable licensing examination as defined by regulation.
o
Completion of an acceptable 2-hour education course in pain management and opioid use and addiction.
o
Must be actively licensed in at least one other state
o
NOT have a license to practice medicine in another state, province, or territory suspended or revoked
Locum Tenens Permit – International Graduates:
o
Successful graduation from a medical school listed in the Medical Board of California List of Approved
Medical Schools.
o
Successful completion of three years of post-graduate training at an accredited program in a recognized
hospital
in the U.S. or Canada
o
Successful passage of an acceptable licensing examination as defined by regulation
o
Completion of an acceptable 2-hour education course in pain management and opioid use and addiction
o
ECFMG Certificate
o
Must be actively licensed in at least one other state
o
NOT have a license to practice medicine in another state, province, or territory suspended or revoked
Resident Permit:
o
Acceptance by an eligible institution in Alaska for the purpose of residency or internship
HOW CAN YOU HELP?
1. First and foremost: apply far enough in advance to allow for application processing. Please DO NOT
move to Alaska until you have a permit or license in hand.
2. If you are concerned about your application being received in our office, mail it certified, return receipt.
3. If you wish to expedite processing as much as you can, send all your verification request forms out via
overnight mail and include a return overnight mail envelope addressed to the licensing examiner for
the organization’s use. This will help them to respond quickly.
4. Whenever available, use online resources to expedite the application process. (AMA Physician Profile,
AOA Official Osteopathic Physician Profile, FCVS, VeriDoc)
5. Ensure the application is complete when you submit it; do not skip any sections or questions. Provide
any necessary explanations with the application. Print legibly or type any “Yes” responses.
6. Provide complete explanations for any “Yes” responses; it saves time if we don’t have to request the
information.
7. Use the applicable checklist provided at the end of these instructions to ensure that you submit all materials.
08-4675 Rev 12/1/2020 Instructions Page 4 of 10
General Information for Licensure
ADDRESS OF RECORD
The Uniform Application asks for your preferred board contact address. This is the address to which you would like us to send all
communications to you including your permit or license. Please do not use third party addresses, telephone numbers, or email
addresses as this creates difficulties when we are trying to reach you.
AMA OR AOA PROFILES
The Alaska State Medical Board requires all applicants to have a copy of their individual Physician Profile Report sent directly to
the Board by the American Medical Association (AMA) or the American Osteopathic Association (AOA), even if you are not a
member of these organizations. You must order the profiles directly from the organizations:
• AMA Profile (MDs only): commerce.ama-assn.org/amaprofiles
• AOA Profile (DOs only): doprofiles.org
APPLICATION FOR LICENSURE BY CREDENTIALS
The Alaska State Medical Board may waive the written examination requirement and license an applicant by credentials if you
hold an active license issued after written examination in another state or territory or the United States or province of Canada.
Such examination must be equivalent to the USMLE examination series or must include passing the following examinations with
at least a minimum passing score as defined by regulation (12 AAC 40.020): the National Board of Medical Examiners (NBME),
the Federation Licensing Examination (FLEX), or the National Board of Osteopathic Medical Examiners (NBOME).
APPLICATION FOR LICENSURE BY EXAMINATION
The Alaska State Medical Board requires the USMLE examination series and has contracted with the Federation of State
Medical Boards for administration of the examination. For more information, fsmb.org/licensure/usmle-step-3
For assistance, email usmle@fsmb.org or call (817) 868-4041
APPLICATION STATUS UPDATES
Licensing staff will send you a written status update upon the initial screening of the application, and periodically throughout the
application process. It is your responsibility to provide your documents and to request or order documents from other agencies
and organizations. Use our convenient online services by registering with MYLICENSE. The online features will help you apply
for a new license, renew an existing license, update your email and mailing address, and receive electronic communication about
application status, licensure, regulations changes, and other important news. ProfessionalLicense.Alaska.Gov/MYLICENSE
APPLICATION SUBMITTAL
Submit application forms and supporting documents by U.S. Mail to:
Alaska State Medical Board
PO Box 110806
Juneau, AK 99811-0806
The U.S. Post Office will not deliver to the physical address.
If you are using a courier delivery service, the physical address is:
CBPL
333 Willoughby Avenue, 9th Floor
Juneau, AK 99811
BOARD REVIEW OF APPLICATIONS
Only the board is authorized to grant licenses. Your application will be presented to the board for review and approval of your
license at a regularly-scheduled board meeting. In most cases, you will be notified via a completion status letter from the
licensing examiner that your file has been forwarded to the executive administrator for review and when the next scheduled
board meeting will occur. In some cases, if there is an issue that requires resolution in your application, your file may be delayed
for a period of time and your file may not be reviewed by the board immediately. If you wish to know when your application will be
considered by the board, please contact the office and advise us as early as possible so that we may accommodate your
request.
CERTIFIED TRUE COPIES
To obtain a certified true copy, take the original document to a notary public so he/she may compare the original to the
photocopy of the document. The notary must write “I certify this to be a true copy of the original document” on the photocopy and
attest to the fact by signing and notarizing the document.
COMPLETION OF THE APPLICATION FORMS
Help us do a good job processing your application: type or print legibly on all application documents. Please read the instructions
and give careful thought before answering the questions in the application remember you are certifying that the information is
truthful and correct. Make sure all notary seals are properly affixed on the application and all documentation has been properly
certified as required. Provide all documents requested in the application; incomplete applications will delay processing.
08-4675 Rev 12/1/2020 Instructions Page 5 of 10
CONFIDENTIALITY
The contents of licensing files are generally considered public records. If you believe that the additional information you are
attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request for confidentiality
may or may not be granted.
CONTINUING MEDICAL EDUCATION REQUIREMENT
Alaska law requires an average of 25 hours of Category I AMA- or AOA-approved continuing education hours for each year of
the licensing period (two-year licensing cycle). At the time of renewal, the licensee must attest to compliance with the CME
requirements. After renewal is completed, the division will perform a computer- generated random audit of licensees who will be
required to provide proof of CME courses. Please see regulations 12 AAC 40.200, 210, and 220.
DEA CLEARANCE REPORT
You are required to request a clearance report from the Drug Enforcement Administration for your DEA registration. Use the form
provided in this packet. Send your request to:
Drug Enforcement Administration
300 5th Avenue, Suite 1300
Seattle, WA 98104
DENIAL OF LICENSE
The denial of an application for licensure may be reported to any person, professional licensing board, federal, state, or local
government agency, or other entity making a relevant inquiry or as may be required by law.
EXAMINATION SCORES
Regardless of your application, whether by credentials or examination, Alaska requires that you must pass each component of
your examinations with a minimum two-digit score of 75. If you are applying for licensure by examination and fail any component
more than once, you will be required to complete a supervised course of study acceptable to the board before permission to
retake the step will be given.
Unless you are using FCVS for credentials verification, you must request exam scores be sent to the board from the appropriate
organization. There may be a fee involved. If using FCVS, this will be handled for you.
• USMLE / FLEX / SPEX – Request transcripts at fsmb.org/licensure/fcvs
For assistance, email usmle@fsmb.org or call (817) 868-4041 with your USMLE ID.
• NBME – Request your scores at: https://apps.nbme.org/ciw2/prod/jsp/login.jsp
For assistance, email scores@nbme.org or call (215) 590-9500
• NBOME/COMLEX-USA – Request a certified copy of your official transcript at: nbome.org/transcript-request.asp
For assistance, send a message to Client Services at nbome.org/contactform.asp or call (866) 479-6828.
• State Board Examination – Request the state board or jurisdiction to send your state exam information directly to the
Alaska State Medical Board. A directory of state medical and osteopathic boards is available at fsmb.org/policy/contacts
• LMCC – Complete the Service Request form at: mcc.ca/forms/certified-transcript-examinations
For assistance, email service@mcc.ca or call (613) 521-6012
• ECFMG Certificate or Status Report – Request a Status Report at cvsonline2.ecfmg.org
For assistance, email credentials@ecfmg.org or call (215) 386-5900.
FAX DOCUMENTS
Fax copies of documents are NOT accepted for documentation or verification in our licensing process.
FEDERATION CREDENTIALS VERIFICATION SERVICE (FCVS)
The Federation of State Medical Boards offers a credentials verification service that is accepted by the Alaska board. This
verification process is conducted separately and independently by FCVS in accordance with established policies and procedures
set forth by the Board. FCVS staff uses primary sources to verify a physician’s identity, education, training, and more, and
creates a permanent profile of the verified credentials. The profile can be updated as needed throughout a physician’s career and
sent to boards and other entities without the need to verify each item again.
If you are using FCVS for credentials verification, do not provide a copy of your driver’s license or passport, or a copy of any
name change documents to the Board. Also, do not provide examination scores/transcripts, verification of medical education and
official transcript, or verification of postgraduate training to the Board. FCVS will provide these verified credentials to the Board
on your behalf.
To use FCVS, visit fsmb.org and select “FCVS” from the Sign In menu in the upper right corner. Sign in and continue as directed.
Complete an Initial Application if you are using FCVS for the first time. Complete a Subsequent Application if you need to update
an existing FCVS profile. During the application process, designate your profile to be received by the Alaska State Medical
Board. For assistance, contact FCVS through the messaging tool within FCVS, or call (888) 275-3287 with your FCVS ID
number. Please do not contact the Alaska State Medical Board regarding your FCVS application.
08-4675 Rev 12/1/2020 Instructions Page 6 of 10
FSMB BOARD ACTION DATABANK REPORT
The Alaska State Medical Board requires all applicants to have a copy of their individual Board Action Databank Report sent
directly to the Board by the Federation of State Medical Boards Physician Data Center (FSMB PDC). The form is included in this
packet for your convenience.
FEES
For permanent licenses, you may remit a minimum of $600 (nonrefundable application fee and $200 temporary permit fee) at the
time of application so that a temporary permit may be issued. However, the balance of $225 must be paid before the permanent
license is issued. All applications must be accompanied by the appropriate fee. Personal checks, cashier’s checks, or money
orders must be made payable to the State of Alaska.
Permanent Physician License:
Nonrefundable Application Fee $400
License Fee $425
Total Due $825
Podiatric Medicine License:
Nonrefundable Application Fee $400
License Fee $425
Total Due $825
Courtesy License:
Nonrefundable Application Fee $100
License Fee $150
Total Due $250
Locum Tenens Permit:
Nonrefundable Application Fee $150
Permit Fee $150
Total Due $300
Resident Permit:
Nonrefundable Application and Permit Fee $100
Total Due $100
Incorrect fees will delay processing of your application.
FOREIGN LANGUAGE DOCUMENTS
All foreign language documents must be certified true copies and must be accompanied by a certified translation into
English by a recognized translator.
INITIAL LICENSURE IN SECOND YEAR OF TWO-YEAR CYCLE
If you were initially licensed in the second year of the two-year licensure period, within 12 months of the date of expiration
(December 31, even-number years), you will pay the entire license fee. Upon renewal, you will receive a renewal form that pro-
rates the licensure fee for the coming licensure period. You will pay one-half of the required license renewal fee at the time of
renewal.
If your permanent license was first issued to you after October 1 of the second year of the licensing period, you will pay the initial
full license fee; however, your license will be issued showing the expiration date of the next biennial licensing period. For
example, if your initial license was issued October 18, 2014, the expiration date will automatically be entered as December 31,
2016.
LICENSE APPLICATION PROCESSING STAFF
All inquiries should be directed to the State Medical Board (907) 269-8163 or medicalboard@alaska.gov
LICENSE RENEWAL
All medical licenses in Alaska are on a two-year cycle, with all licenses expiring December 31 of even-numbered years.
Notification for license renewal is mailed out to license holders of record at least 30 days prior to expiration, usually in late
October. You are required by law to keep your current address on file with the division (12 AAC 02.900).
Failure to receive a renewal notice is not considered an excuse for nonrenewal. A physician who is not intending to practice
medicine in Alaska may renew their license in an inactive status. If you practice in the state occasionally, you must renew your
license in active status. An inactive status license prohibits you from practicing; however, if you wish to reactivate your inactive
license, contact the licensing examiner for instructions.
It is illegal to practice medicine in Alaska with an inactive or lapsed license or permit.
08-4675 Rev 12/1/2020 Instructions Page 7 of 10
LICENSING PROCESS
Submit your complete application to the Board with fees and pertinent documents. Licensing staff will assemble the documents
for your application file and advise you of the application status. Upon the completion of the application file when all documents
have been received from other organizations, the file is forwarded to the Board’s administrator who reviews the entire file. At the
discretion of the administrator, a temporary permit may be issued (see information under Temporary Permit on page 7).
The complete application file is presented to the board at its next regularly-scheduled meeting. The Board meets four times each
year. Following the Board’s review and approval, the licensing examiner will issue the permanent license.
Applications will be processed in the order in which they are received in the Board’s office. Please ensure that you apply well in
advance of your need for the permit or license. Board staff will not expedite one application before another.
NAME CHANGES
Unless you are using FCVS for credentials verification, if you have changed your name at any time during your life, you must
submit a copy of the legal document (marriage certificate, divorce decree, etc.) supporting your name change. If you are using
FCVS, the copies will be included in your profile.
OPIOID EDUCATION
A two-hour education course (equivalent to a continuing medical education program) is required to qualify for a new license in the
State of Alaska, unless you do not hold a valid DEA registration. Courses must be category 1 of AMA-approved education, or
Category 1 or 2 of AOA-approved education. For a podiatrist, it may be earned in a continuing medical education program from a
provider that is approved by the Council on Podiatric Medical Education (CPMR). To document compliance with the opioid
education requirement, the title/description of the program on your Certificate of Completion should specifically reference all
three areas of the required subject matter: pain management, opioid use, and addiction.
PAYMENT OF CHILD SUPPORT
If the Alaska Child Support Enforcement Division has determined that you are in arrears on child support, or if the Alaska
Commission on Post-Secondary Education has determined you are in loan default, you may be issued a nonrenewable
temporary license valid for 150 days. Contact Child Support Services at (907) 269- 6900 or the Post-Secondary Education office
at (907) 465-2962 or 1(800) 441-2962 to resolve payment issues.
PERSONAL INTERVIEWS
Applicants for medical licensure in Alaska may be required to have a personal interview with the board. Should an interview be
required, you will be notified, and an interview scheduled for the next board meeting. An interview may be required if, during the
processing of your application, a question arises for which the board determines it requires additional information from you.
PRACTICING IN ALASKA
For information on practice opportunities, please refer to the Job Opportunities page of the Alaska State Medical Association
website at: asmadocs.org/job-opportunities
PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
All Alaska-licensed practitioners with a DEA registration must register with the Prescription Drug Monitoring Program (PDMP)
and use the PDMP to review a patient's prescription history each time before prescribing a federally scheduled II or III controlled
substance. PDMP.Alaska.Gov
PROCESSING TIME
In general, average processing time for a temporary permit is from twelve to fourteen weeks. Please plan accordingly.
Application processing time depends to a large extent on the response time from other organizations. Time required also
depends upon our workload and the volume of applications being processed. Because the length of processing time for your
application may vary considerably, we urge you to be patient until our processing is complete and the permit is issued.
If there are any “Yes” responses or if adverse information is received, it will typically take longer to gather and evaluate additional
data. If the application is referred to the Investigations Unit for investigation of a particular issue, processing time is extended by
the time required to complete an investigation. Since investigations must be prioritized, it may take longer to complete the file.
SOCIAL SECURITY REQUIREMENT
Alaska Statute 08.01.060(b) requires an applicant for an occupational license to provide a United States social security number.
Applicants who are foreign citizens and are unable to obtain a social security number must contact the division office for
instructions. Social security numbers are required by federal law to be held confidential; we do not release these numbers to the
public.
STALE DOCUMENTS
If during the license application process certain documents become older than six months from the date the document was
received in our office, that document is considered to be stale and must be resubmitted. Affected documents include the
application, verifications of licensure from other licensing jurisdictions, the DEA clearance report, and the FSMB Board Action
Data Bank report.
08-4675 Rev 12/1/2020 Instructions Page 8 of 10
STATE BUSINESS LICENSES
Physicians who are employees do not need to obtain an Alaska state business license; physicians who are independent
contractors must obtain a state business license. You may obtain a business license by contacting:
Division of Corporations, Business, and Professional Licensing Business Licensing Section
Post Office Box 110806 Juneau AK 99811-0806 (907) 465-2550
professionallicense.alaska.gov/
TELEPHONE QUERIES
We have a very small staff and work hard to process applications as quickly as possible. Unnecessary telephone calls to our
offices delay processing. If the licensing examiner must spend time answering numerous telephone queries, application
processing time is affected.
Because of the huge volume of telephone calls regarding the status of applications and because of privacy issues, we must
restrict our telephone responses to the applicant only. We will not discuss your application with others. If you are concerned
about your application being received in our office, mail it “certified – return receipt requested.” You will have a verification of
delivery returned to you by the post office.
TEMPORARY PERMIT
After your application for a permanent license is complete, it is forwarded to the board’s executive administrator. Following her
review, she may authorize the issuance of a temporary permit. Since the board only meets four times each year, the temporary
permit is a courtesy to you to allow you to practice until the next board meeting when your file will be considered. The permit will
be mailed to you at the address you specify in your application. Should a personal interview be required, the temporary permit
may be issued at the conclusion of the interview.
VERIDOC – LICENSE VERIFICATION SERVICE
We recommend the use of VeriDoc to expedite processing of licensure verification from other states to the Alaska Board.
VeriDoc eliminates the time delay often experienced when relying on post office mail. Visit www.veridoc.org for more information
or to use this system.
WEBSITE ADDRESS
The Division of Corporations, Business, and Professional Licensing maintains a website where you may obtain general
information about the board or check to see if your license or permit has been issued: professionallicense.alaska.gov/
WITHDRAWAL OF APPLICATIONS
The Board permits the withdrawal of an application that it has not yet considered at a board meeting. Should you wish to
withdraw your application, please submit a request in writing stating the reason for the withdrawal. Requests must be received
before the first time the Board reviews and considers the application. All withdrawals are reported to the Federation of State
Medical Boards stating the reason for the withdrawal.
“YES” RESPONSES
A “Yes” response in the application does not mean your application will be denied. If you have responded “Yes” to any question
in the application, additional time will be required for the gathering and assessment of pertinent information. You can expedite
this process by providing with your application complete explanations and documentation for any “Yes” responses.
08-4675 Rev 12/1/2020 Instructions Page 9 of 10
Uniform Application for Physician State Licensure
The UA was developed to simplify the licensure application process by eliminating redundancy. Once the core UA is
completed, it can be sent when applying to another participating board without the need to reenter information.
Updates can be made as needed.
As part of the online UA, you will be asked to complete a chronology of activities of all working and non-working time
since medical school graduation and provide details of any malpractice liability claims. Having this information on
hand before you begin will help you to complete the UA more efficiently.
To use the UA, visit fsmb.org and select “Uniform Application (UA)” from the Sign In menu in the upper right corner.
Sign in and continue as directed.
Please note:
• The business address and home address must be two different addresses. You can select one of the
addresses for both public contact and board mailings, if you like.
• Please ensure that your United States Social Security Number is listed correctly within the UA. It is required
by state law, is considered CONFIDENTIAL information, and is not for public disclosure; it may be used to
verify interstate licensure.
• Information on USMLE, FLEX, and SPEX exams and medical licenses issued in the U.S. and Canada will
be pre-filled in your UA. All other examination information (NBME, NBOME, COMLEX, COMVEX, LMCC,
state board exams, etc.) must be entered. If you are not using FCVS and need to request transcripts from an
examination entity, see the information on page 4 for contact information.
• License information in the UA is reported to the FSMB by state boards. If you see incorrect information
listed, email ua@fsmb.org with the correct information. It may take 1-2 business days for the updated
information to show within your UA.
• For each malpractice case listed (all settlements, judgments, awards, and claims, even if no money was
paid), provide an explanation in the specifics area and provide documentation. Include a brief description
regarding the nature of the case, the allegations, and your response to the allegations. Letters from
attorneys or insurance carriers may not be substituted for this required explanation. Documentation includes
a copy of the order for settlement, dismissal, or removal from the case, or other documentation to support
your explanation. Do not send all of the motions or filings for the case.
• We strongly recommend printing or saving a copy of your UA for your records when prompted.
In addition to completing the core UA:
• Complete the state addendum and other forms in this packet as instructed.
• Have each professional license you have ever held (including EMT, nursing, etc.) verified by the board that
issued the license. Determine the fees and preferred verification method for each state medical board by
using the resource at: fsmb.org/licensure/uniform-application
If the verifying board uses VeriDoc or another electronic method, use that instead of the form in this packet.
• Follow the appropriate checklist to ensure that you have sent all required materials to the Board.
For UA assistance, see the UA FAQ at: fsmb.org/licensure/uniform-application/faq
If your issue is not listed, contact UA customer service at (800) 793-7939 or ua@fsmb.org with a description of the
problem. Please email a screenshot to ua@fsmb.org if you see an error.
08-4675 Rev 12/1/2020 Addendum Page 5 of 9
WHEN IN DOUBT, DISCLOSE AND EXPLAIN
DISCIPLINARY HISTORY
1.
Have you ever been convicted of a crime (felony or misdemeanor) in any
jurisdiction of the United States, including military, or any international jurisdiction?
Yes No
Is any such action pending?
Yes No
2.
Have you ever been charged with a crime (felony or misdemeanor) in any
jurisdiction of the United States, including military, o
r any international jurisdiction
that did not result in acquittal or dismissal?
Yes No
Is any such action pending?
Yes No
3.
Relating to the practice of medicine, has there ever been a finding of, or have you
ever been found guilty of, professional
misconduct, unprofessional conduct,
incompetence, or negligence, by any
jurisdiction of the United States, including
military, or any international jurisdiction?
Yes No
Is any such action pending?
Yes No
4. Relating to the practice of medicine, have
you ever had charges filed against you
alleging
professional misconduct, unprofessional conduct, incompetence, or
negligence, in any jurisdiction of the United States, including military, or any
international jurisdiction?
Yes No
Is any such action pending?
Yes No
5. Has any hospital or other health care facility disciplined, restricted, or terminated
your professional training, employment, or privileges, or investigated a complaint or
accusation regarding your practice (except for late medical records)?
Yes No
Is any such action pending?
Yes No
6.
Have you ever voluntarily or involuntarily resigned or withdrawn from professional
training, from employment, or your privileges from any hospital or other health care
facility to avoid the imposition of disciplinary sanction, restriction or termination?
Yes No
Is any such action pending?
Yes No
7. Have you ever been disciplined by a medical school or post-
graduate training
program, including academic probation?
Yes No
Is any such action pending?
Yes No
8.
Have you ever had a license to practice medicine disciplined by any authority
including a state medical board or a military authority (except for late medical
records)?
Yes No
If you are unsure about your response to this question, please refer to the
instructions and definitions for this section on page 2 of this addendum.
When in doubt, disclose and explain.
Is any such action pending?
Yes No
08-4675 Rev 12/1/2020 Addendum Page 6 of 9
DISCIPLINARY HISTORY (continued)
9. Have you ever been under investigation by
any medical licensing jurisdiction or
authority?
Yes No
If you are unsure about your response to this question, please refer to the
instructions and definitions for this section on page 2 of this addendum.
When in doubt, disclose and explain.
Is any such action pending?
Yes No
10. Have you ever had a
medical license application denied by any medical licensing
jurisdiction or authority?
Yes No
Is any such action pending?
Yes No
11. Have you ever voluntarily or involuntarily withdrawn an applica
tion for a license to
practice medicine in any United States jurisdiction or any international jurisdiction?
Yes No
Is any such action pending?
Yes No
12.
Have you ever voluntarily or involuntarily surrendered or suspended your license to
practice medicine in any United States jurisdiction or any international jurisdiction?
Yes No
Is any such action pending?
Yes No
13.
Have you ever voluntarily or involuntarily agreed to any limitations, restrictions, or
conditions to your license to practice medicine?
Yes No
Is any such action pending?
Yes No
14.
Has your employment by a clinic, hospital, or other health care organization ever
been terminated involuntarily or voluntarily as a result of an actual or potential
investigation or as grounds for disciplinary proceedings?
Yes No
Is any such action pending?
Yes No
08-4675 Rev 12/1/2020 Addendum Page 7 of 9
Personal History
The following questions must be answered. “Yes” answers may not automatically result in license denial.
For each “Yes” response to any question, you must provide an explanation and documentation. Provide your
explanation on a separate sheet of paper labeled with your name, and signed by you; include full details, dates,
locations, type of action, organizations or parties involved, and specific circumstances. Documentation includes copies
of court records, judgments, charging documents, etc. You must also have your treating physician submit a letter
directly to the Board; the letter must include the following information:
•
Summary of your diagnoses
(including explanation, dates of onset and significant events, and frequency of contact with you)
• Medication history
• Impact on your ability to practice safely and competently
Applications submitted without the required attachments will be considered incomplete and will not be processed.
The contents of licensing files are generally considered public records. If you believe that the additional information
you are attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request
for confidentiality may or may not be granted.
When in doubt about your response, disclose and provide the required explanation and documents. For the purposes
of the questions in this section:
“Medical Condition” includes physiological, mental, or psychological conditions or disorders, such as, but not limited
to, orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple
sclerosis, cancer, heart disease, diabetes, mental retardation, emotional or mental illness, specific learning disabilities,
HIV disease, tuberculosis, drug addiction, and alcoholism.
““Controlled Substances” means any substance as defined in either Alaska Statute 11.71.900 or the Federal
Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C.A. Section 801 et seq. (Public Law 91-
513) and any subsequent amendment(s).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application;
rather, “currently” means recently enough so that the event, condition, behavior, impairment, limitation, etc., may have
an ongoing impact on the applicant’s ability to practice medicine in a competent manner.
“Illegal Drug Use” means the use of an illegally obtained controlled substance or dangerous drug; the term “illegal
drug use” also means the use of a legally obtained controlled substance or dangerous drug which is not taken in
accordance with the directions of the licensed physician who prescribed the controlled substance or dangerous drug.
WHEN IN DOUBT, DISCLOSE AND EXPLAIN
0
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Instructions Forms & Instructions (Federation of State Medical Boards)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document