Kansas State Board of Healing Arts Uniform Application Instructions
Last revised May 2016 Page 1 of 3
Phone: 785-296-7413
Toll Free: 888-886-7205
Kansas State Board of Healing Arts
800 SW Jackson, Lower Level, Suite A
Topeka, KS 66612
www.ksbha.org
KANSAS LICENSURE APPLICATION INSTRUCTIONS
MEDICINE & SURGERY (MD) and OSTEOPATHIC MEDICINE & SURGERY (DO)
Please visit www.ksbha.org for all statutes and regulations
Completing the Kansas Licensure Application
Review the following instructions carefully before completing the application. This information is vital to the
successful completion of your application. Failure to submit all required information and documentation will result in
processing delays. Please allow two (2) weeks after the submission of the application before contacting our office. Do
not make a commitment to any work dates prior to being licensed.
Kansas does not have direct reciprocity with any state. All applicants are considered on an individual basis. You may
be requested to submit information or documentation in addition to the requirements mentioned herein before the
application will be deemed complete. It is highly recommended you make and keep copies, for your records, of all
items submitted for review. Do not send original forms or documentation to the Board.
In completing the application, you will be asked to account for all time since medical school graduation and list all
Malpractice Liability Claims Information. Having this information on hand before you begin your session will
facilitate completing your application.
If you have any questions about the information provided to you in the application packet, please contact our office at
785/296-7413. Thank you for applying for licensure in the State of Kansas.
The Federation Credentials Verification Service (FCVS)
The Board accepts the use of FCVS as part of the licensure process. FCVS staff creates a permanent profile of primary
source verified documents related to identity, medical education, postgraduate training, and more. The profile can be
updated as needed and sent to boards and other entities without the need to verify each item again.
Applicants using FCVS to verify their credentials are still required to complete the Kansas State Board of
Healing Arts Uniform Application (UA). If you do not use FCVS, you must provide your credentials to the Board for
verification along with completing the UA.
For clarification, the Uniform Application (UA) is used to apply for state licensure. The FCVS application is used only
to create or update a personalized profile of primary source verified credentials for use in the overall licensing process.
To use FCVS, visit http://www.fsmb.org/ and select “FCVS” in the Licensure or Sign In menu, then sign in and
continue as directed. Users with existing FCVS profiles should complete a Subsequent FCVS Application to ensure the
profile is up to date. New FCVS users should complete the Initial FCVS Application. All users must, during the
application process, designate the Kansas State Board of Healing Arts to receive the FCVS profile. Self designations
are not accepted.
More information about FCVS is available at http://www.fsmb.org/licensure/fcvs/. For assistance, use the messaging
tool within FCVS or call 888-275-3287 with your FCVS ID number between 8am and 5pm CT on weekdays.
Kansas State Board of Healing Arts Uniform Application Instructions
Last revised May 2016 Page 2 of 3
The Uniform Application for Physician State Licensure (UA)
This packet contains a version of the UA that can be completed and mailed to the Board instead of completing the UA
online. There is no fee for using the paper UA.
Please note the following:
The Board requires that you submit your valid National Provider ID number in the space provided.
Accepted examinations are National Boards (NBME, NBOME), FLEX, USMLE, State Examinations, LMCC,
COMLEX, or a combination of FLEX, USMLE, and National Boards. Applicants who took the FLEX prior to
June 1985 must have passed with a FLEX weighted average of 75 or higher, attained in one sitting. Applicants
who took the USMLE must complete all steps within 10 years.
List all professional licenses (nurse, EMT, physician assistant, etc.) you have held in the U.S. or Canada,
regardless of status (active, inactive, etc.). If you hold licenses in countries outside the U.S. or Canada, please
provide that information on a separate sheet of paper to the Board. Use the Licensure Verification form in this
packet to request license verifications from each board.
On the Chronology of Activities, for military or locum tenens assignments, list each location/assignment
separately. Additionally, for military service, please provide a copy of your discharge or separation documents.
For all locations where you have had admitting privileges, check the “Staff Privileges” box.
For all malpractice, claims include a written statement from the insurance company or insurance / personal /
institution attorney. Include date of occurrence, name of the insurance company involved on your behalf, name
of claimant(s), other defendant(s) and/or institution involved, list of all attorneys involved, case number and
location of filing, status of the matter, and summary of the occurrence; or you may provide court documents.
Failure to provide complete information will result in delay of processing the application.
In addition to completing the core UA, all applicants must:
Complete the state addendum.
Submit a notarized UA Affidavit and Authorization for Release of Information form to the Board. This is a
separate form from the FCVS Affidavit and must be sent to the Kansas State Board of Healing Arts. Attach a
recent (less than 6 months old) two inch by two inch (2” x 2”) passport-type color photograph of yourself in
the space provided. Proof photos, negatives, and digital photos are not acceptable.
Please note that by signing the Affidavit and Authorization for Release of Information form, you agree to the
following:
I have carefully read the questions in the foregoing application and have answered them
completely, without reservations of any kind, and I declare under penalty of perjury that my answers
and all statements made by me herein are true and correct. Should I furnish any false information in
this application, I hereby agree that such act shall constitute cause for the denial, suspension or
revocation of my license to practice medicine and surgery, osteopathic medicine and surgery,
chiropractic or podiatry in the state of Kansas and may subject me to a fine not exceeding $10,000 and
term of imprisonment not exceeding 5 years for each violation. (K.S.A. 21-3805)
KSBHA will verify each of your medical board licenses except for any board that does not provide free,
current verifications and disciplinary actions on their official website. For those boards, use the licensure
verification resource at http://www.fsmb.org/licensure/uniform-application/ to determine the fees and preferred
verification method of each board. Use the Licensure Verification form in this packet for boards requiring a
written request. You may use VeriDoc or another preferred method if applicable.
Kansas State Board of Healing Arts Uniform Application Instructions
Last revised May 2016 Page 3 of 3
If you are using FCVS for credentials verification,
Do not complete the UA Medical Education, Postgraduate Training, or Fifth Pathway Verification forms, or
send identity documents, transcripts, certificates, or examination scores to the Board. FCVS obtains this
information and sends it to the Board as part of your FCVS profile of verified credentials.
If you are not using FCVS for credentials verification,
Send to the Board a certified copy of a legal name change document (marriage certificate, divorce decree,
court order) if your name is not the same on all of your submitted documents.
Complete the UA Medical Education Verification, Postgraduate Training Verification, and Fifth Pathway
Verification (if applicable) forms as directed on each form.
Submit a notarized copy of your medical school diploma(s). The diploma(s) must be notarized as a true and
accurate copy of the original. Note: Diplomas in languages other than English must be translated and the
translation certified as accurate. Documents without such certification will not be accepted.
Contact each appropriate examination entity to have a certified transcript of your scores sent directly from the
exam entity to the Board. If you have taken any component of the NBME in conjunction with another exam
(USMLE/FLEX), request your transcript of scores from the NBME. For exam entity contact information, see
the UA FAQ at http://www.fsmb.org/licensure/uniform-application/faq.
International Medical Graduates: Submit a notarized copy of your ECFMG Certificate to the Board. It must be
notarized as a true and accurate copy of the original. Also request that a “Status Report of ECFMG
Certification” be sent directly to the board. If you attended a Fifth Pathway Program, request that the Fifth
Pathway Program Certificate be sent to the Board. See the UA FAQ link above for contact information.
Additional Licensure Information / Requirements
Application Fee. The Kansas application fee is $300.00. It must be submitted with the application and is NOT
refundable. You may pay by check, debit card, Visa, MasterCard, Discover, American Express or money
order. Make checks payable to KSBHA. Checks returned for any reason by the payer’s financial institution
must be replaced by a money order, certified check, debit card or credit card.
AMA and AOIA Reports. MDs must request the AMA report from the American Medical Association at
https://profiles.ama-assn.org/amaprofiles/ or call 800-665-2882. DOs must request the AOIA report from the
American Osteopathic Information Association at https://www.doprofiles.org or call 800-621-1773 x8145.
Criminal Background Report. Effective January 1, 2009, applicants to practice the healing arts will be
required to submit their fingerprints for state and national criminal history background checks. Addendum 5
explains in detail how to obtain and submit your fingerprints to the Board. Be aware that fingerprint
processing may delay your application. Please make it a PRIORITY to complete the fingerprint process.
Complete, sign and return the Waiver Agreement and Statement form directly to the Board.
National Practitioner Data Bank Report. Effective September 1, 1990, the Federal government opened the
National Practitioner Data Bank (NPDB). This data bank, mandated by Congress, tracks regulatory board
disciplinary actions, certain actions resulting from peer review and malpractice payments. The Kansas State
Board of Healing Arts will obtain a NPDB report for all applicants. Applicants will be required to
submit the report fee of $3.00 to the Board.
License Renewals. MD licenses expire on July 31 and are renewed annually. License renewal will be required
of all MD applicants receiving permanent licenses prior to May 1. DO licenses expire on October 31 and are
renewed annually. License renewal will be required of all DO applicants receiving permanent licenses prior to
August 1.
Kansas State Board of Healing Arts Uniform Application Checklist
Last revised May 2016
UNIFORM APPLICATION FOR PHYSICIAN STATE LICENSURE
CHECKLIST
After completing the Uniform Application, you are responsible for submitting certain documents. There are two
checklists below; one to use if you are using the Federation Credentials Verification Service (FCVS) and one to use if
you are not using FCVS. Please use the checklist that applies to you.
NOT using FCVS
to verify
credentials
Using FCVS
to verify credentials
Completed Uniform Application (UA).
Completed state addenda and fees (licensure fee of $300 plus National
Practitioner Data Bank Report fee of $3) sent to the Board.
Notarized UA Affidavit and Authorization for Release of Information
form sent to the Board.
UA Licensure Verification form sent to the Board from each state board
through which you have ever held any physician license if KSBHA is
unable to verify the license.
American Medical Association or American Osteopathic Information
Association report sent to the Board from the AMA or AOIA.
Fingerprint card.
Notarized copy of birth certificate or current, valid passport sent to the
Board.
Completed via FCVS
Supporting documentation of any legal name change sent to the Board.
Completed via FCVS
Medical Education Verification form sent to the Board from all medical
schools attended.
Completed via FCVS
Medical School Transcripts sent to the Board by your medical
school(s).
Completed via FCVS
Notarized copy/copies of medical school diploma sent to the Board.
Completed via FCVS
Postgraduate Training Verification form sent to the Board from all
programs you attended.
Completed via FCVS
Copy of your postgraduate training certificate(s) sent to the Board.
Completed via FCVS
Fifth Pathway form (if applicable) sent to the Board from the medical
school and institution - include a copy of your diploma (must be sealed
by your school).
Completed via FCVS
Examination Transcripts sent to the Board.
Completed via FCVS
ECFMG Status Report (if applicable) sent to the Board.
Completed via FCVS
Notarized copy of ECFMG Certificate (if applicable) sent to the Board.
Completed via FCVS
Kansas State Board of Healing Arts Applicant Name __________________________________ Uniform Application Addendum
Last revised May 2016 Instructions
Kansas State Board of Healing Arts Phone: 785/296-7413
800 SW Jackson, Lower Level, Suite A Toll Free: 888/886-7205
Topeka, KS 66612 www.ksbha.org
KANSAS LICENSURE APPLICATION ADDENDUM INSTRUCTIONS
MEDICINE & SURGERY (MD) and OSTEOPATHIC MEDICINE & SURGERY (DO)
Please visit www.ksbha.org for all statutes and regulations
Completing the Kansas Licensure Addendum
Complete each addendum as instructed. Please type or print your responses. Return the completed addenda along
with any and all supporting documentation to the Kansas State Board of Healing Arts at the address above.
Addendum 1
Addendum 2
Addendum 3
Addendum 4
Addendum 5
Credit Card
Payment
Authorization
Form
Medicine & Surgery
Kansas State Board of Healing Arts Applicant Name __________________________________ Uniform Application Addendum 1
Last revised May 2016
ADDENDUM 1
KANSAS STATE BOARD OF HEALING ARTS
Select the discipline applying for and the license designation being requested.
Osteopathic Medicine & Surgery
Federal Active
Inactive
Exempt
A license issued to a person authorizing the practice of medicine and surgery, osteopathic medicine and
surgery, chiropractic or podiatry. Applicants for active licensure must provide evidence of professional
liability insurance (which will be in effect as of the date of licensure) in compliance with Kansas law
before a license will be issued. Each active license may be renewed annually. Licensees must maintain
and submit evidence of satisfactory completion of a program of continuing education. Licensees must
maintain and submit evidence of professional liability insurance, and contribute to the Kansas Health
Care Stabilization Fund (more information about this fund can be found here: https://hcsf.kansas.gov/).
A license issued to only a person who meets all the requirements for a license to practice the
healing arts in Kansas and who practiced that branch of the healing arts solely in the course of
employment or active duty in the United States government or any of its departments, bureaus or
agencies or who, in addition to such employment or assignment, provides professional services as a
charitable health care provider as defined under K.S.A. 75-6102. Continuing education, expiration
and renewal of a license shall be applicable to a federally active license. A person who practices
under a federally active license shall not be deemed to be rendering professional service as a health
care provider in this state and is not required to have policy of professional liability coverage in
effect.
A license issued to a person who is not regularly engaged in the practice of the healing arts in
Kansas and who does not hold oneself out to the public as being professionally engaged in such
practice. An inactive license shall not entitle the holder to practice the healing arts in this state. Each
inactive license may be renewed annually. The holder of an inactive license shall not be required to
submit evidence of satisfactory completion of a program of continuing education and is not required to
have basic coverage or self-insurance in effect solely because such person is no longer engaged in
rendering professional service as a health care provider.
A license issued to a person who is not regularly engaged in the practice of the healing arts or
podiatry in Kansas and who does not hold oneself out to the public as being professionally
engaged in such practice. Each exempt license may be renewed annually. The holder of an
exempt license is entitled to all the privileges of their branch of the healing arts and (1) may serve
as a coroner or as a paid employee of a local health department as defined by K.S.A. 65-241; or (2)
practice as a charitable health care provider for an indigent health care clinic as defined by
K.S.A. 75-6102. Additionally, the holder of an exempt license may perform administrative
functions. The holder of an exempt license shall not be required to submit evidence of
satisfactory completion of a program of continuing education nor are they required to have basic
coverage or self-insurance in effect.
List intended professional activities: _______________________________________________
Additional Information:
1. Have you ever been licensed to practice the Healing Arts in Kansas? Yes No
Active
2. Give location of intended practice in Kansas _____________________________________________________
3. Primary Specialty __________________________________________________________________________
American Board Certified ____________________ American Board Eligible ____________________
Kansas State Board of Healing Arts Applicant Name __________________________________ Uniform Application Addendum 2
Last revised May 2016 Page 1 of 2
ADDENDUM 2
KANSAS STATE BOARD OF HEALING ARTS
Please answer each of the following questions. All “yes” answers MUST be thoroughly explained in detail on a
separate signed page. You are required to furnish complete details including date, place, reason, and disposition of the
matter and attach all relevant documentation. All information received will be checked accordingly to verify the truth
and veracity of your answers. It is imperative you honestly and fully answer all questions, regardless of whether you
believe the information requested is relevant.
If you are unsure of your response to a question, check the “yes” box and submit the appropriate documentation. Your
responses on your application are evaluated as evidence of your candor and honesty. An honest “yes” answer to a
question on your application is not definitive as to the Boards' assessment of your present moral character and fitness,
but a dishonest “no” answer is evidence of a lack of candor and honesty. Please be advised that a false response to any
of these questions may be grounds for denial of licensure. If a question is not applicable, then check the “no” box.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1. Have you ever been dropped, suspended, expelled, fined, placed on probation, allowed to
resign, requested to leave temporarily or permanently, or otherwise had action taken against
you by
any professional training program prior to completing the training?
2. Have you ever had any application for any professional license refused or denied by any
licensing authority?
3. Have you ever been refused or denied the privilege of taking an examination required for any
professional licensure?
4. Have you ever been warned, censured, disciplined, had admissions monitored, had privileges
limited, suspended, revoked or placed on probation, or have you ever involuntarily or
voluntarily (to avoid disciplinary action or investigation) resigned or withdrawn from any
licensed hospital, nursing home, clinic or other health care facility in which you have trained,
including but not limited to residency or postgraduate training programs, or otherwise been a
staff member, been a partner or held privileges?
5. Have you ever been denied staff membership with any licensed hospital, nursing home, clinic or
other health care facility?
6. Have you ever been requested to resign, withdraw or otherwise terminate your position with a
partnership, professional association, corporation or other practice organization, either public or
private?
7. Have you ever voluntarily surrendered any professional license?
8. Has any licensing authority ever limited, restricted, suspended, revoked, censured or placed on
probation or had any other disciplinary action taken against any professional license you have
held?
9. Have you ever been notified or requested to appear before a licensing or disciplinary agency?
10. To your knowledge, have any complaints (regardless of status) ever been filed against you with
any licensing agency, professional association, hospital, nursing home, clinic or other health
care facility?
11. Has any professional association imposed any disciplinary action against you?
Yes No
Kansas State Board of Healing Arts Applicant Name __________________________________ Uniform Application Addendum 2
Last revised May 2016 Page 2 of 2
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
12. Do
you currently have any physical or mental health condition (including alcohol or substance
use) that impairs your judgment or would otherwise adversely affect your ability to practice
your profession in a competent, ethical, and professional manner?
13. Have you ever been denied a Drug Enforcement Administration (DEA) or state bureau of
narcotics or controlled substance registration certificate or been called before or warned by any
such agency or other lawful authority concerned with controlled substances?
14. Have you ever surrendered your state or federal controlled substances registration, or had it
revoked, suspended, or restricted in any way?
15. Have you ever been notified of any charges or complaints filed against you by any licensing or
disciplinary agency?
16. Have you ever been arrested? Do not include minor traffic or parking violations or citations
except those related to a DUI, DWI or a similar charge. You must include all arrests including
those that have been set aside, dismissed or expunged or where a stay of execution has been
issued.
17. Have you ever been charged with a crime, indicted, convicted of a crime, imprisoned, or
placed on probation (a crime includes both Class A misdemeanors and felonies)? You must
include all convictions including those that have been set aside, dismissed or expunged or
where a stay of execution has been issued.
18. Have you ever been court martialed or discharged dishonorably from the armed services?
19. Have you ever been a defendant in a legal action involving professional liability (malpractice),
or had a professional liability claim paid in your behalf, or paid such claim yourself?
20. Have you ever been denied provider participation in any State Medicaid or Federal Medicare
Programs or in a private insurance company?
21. Have you ever been terminated, sanctioned, penalized, or had to repay money to any State
Medicaid or Federal Medicaid Programs or private insurance company?
Yes No
*It is your continued duty to update the Board on any changes once the application has been submitted.*
Kansas State Board of Healing Arts Uniform Application Addendum 3
Last revised March 2018 Recommendation 1 of 2
ADDENDUM 3
Kansas State Board of Healing Arts
800 SW Jackson, Lower Level, Suite A
Topeka, Kansas 66612
Recommendations from Two Reputable Physicians
The KSBHA requires two (2) recommendations from licensed physicians. Persons attesting to the good character
of the applicant are attesting to the fact that they have known the applicant for at least one (1) year.
Name of Applicant (Printed or Typed): __________________________________ Date of Birth: _______________
This is to certify that I have known Dr. __ (type or print) for _____
years; that he/she is a capable physician and is not addicted to alcohol or drugs.
I further certify that to the best of my knowledge and belief Dr. _ __
is a fit and proper person for endorsement for license by the Kansas State Board of Healing Arts.
(Please type or print)
Name: _________________________________________________________________________
Profession: Please select one: MD DO
Street 1: __________________________________________________________________________
Street 2: __________________________________________________________________________
State/Zip: __________________________________________________________________________
Telephone: __________________________________________________________________________
Signature: __________________________________________________________________________
Date: __________________________________________________________________________
Please mail this document to the Kansas State Board of Healing Arts at the address above.
Thank you. DO NOT RETURN TO APPLICANT.
Kansas State Board of Healing Arts Uniform Application Addendum 3
Last revised March 2018 Recommendation 1 of 2
ADDENDUM 3
Kansas State Board of Healing Arts
800 SW Jackson, Lower Level, Suite A
Topeka, Kansas 66612
Recommendations from Two Reputable Physicians
The KSBHA requires two (2) recommendations from licensed physicians. Persons attesting to the good character
of the applicant are attesting to the fact that they have known the applicant for at least one (1) year.
Name of Applicant (Printed or Typed): __________________________________ Date of Birth: _______________
This is to certify that I have known Dr. __ (type or print) for _____
years; that he/she is a capable physician and is not addicted to alcohol or drugs.
I further certify that to the best of my knowledge and belief Dr. _ __
is a fit and proper person for endorsement for license by the Kansas State Board of Healing Arts.
(Please type or print)
Name: _________________________________________________________________________
Profession: Please select one: MD DO
Street 1: __________________________________________________________________________
Street 2: __________________________________________________________________________
State/Zip: __________________________________________________________________________
Telephone: __________________________________________________________________________
Signature: __________________________________________________________________________
Date: __________________________________________________________________________
Please mail this document to the Kansas State Board of Healing Arts at the address above.
Thank you. DO NOT RETURN TO APPLICANT.
Kansas State Board of Healing Arts Uniform Application Addendum 4
Last revised May 2016
ADDENDUM 4
KANSAS STATE BOARD OF HEALING ARTS
Applicant: Complete this form and email it to boardinquiry@fsmb.org. You must also check the box below.
I hereby certify that I am the individual referenced below and I acknowledge that I have answered all
questions and reported all information on this page truthfully and completely.
Federation of State Medical Boards of the United States, Inc.
400 Fuller Wiser Road, Suite 300 | Euless, TX 76039
Tel (817) 868-4000 Fax (817) 868-4099
Physician Data Center Inquiry Form
Attention: State Board Inquiries
The Kansas State Board of Healing Arts is requesting a PDC Search concerning
the following individual:
Last Name ______________________________________________
First Name ______________________________________________
Middle Name ______________________________________________
Date of Birth ______________________________________________
Daytime Phone ______________________________________________
Email ______________________________________________
Degree (MD, DO, or PA only) ______________________________________
Medical School ______________________________________________
Year of Graduation ______________________________________________
Last Four Digits of Social Security Number____________________________
ECFMG # (if applicable) __________________________________________
NPI Number ______________________________________________
Please mail the result to the following address:
Kansas State Board of Healing Arts
800 SW Jackson, Lower Level – Suite A
Topeka, KS 66612
Addendum 5
A background check is valid for six (6) months. Application for licensure completed after the
six (6) month period will be required to submit a new fingerprint card for a new clearance.
Provide the law enforcement officer with a stamped envelope addressed to KSBHA 800 Jackson
LL-Suite A., Topeka KS 66612 to mail your fingerprint card or electronic scan, and fee. In
addition, you may want to use a mailing service that allows for delivery confirmation to confirm
your fingerprint card and payment have been received at the Board. Bent and folded cards will not
be accepted and a new fingerprint card will be mailed to you for prints to be taken again.
INSTRUCTIONS FOR REQUESTING A CRIMINAL BACKGROUND CHECK
Effective January 1, 2009, applicants to practice the healing arts will be required to submit their
fingerprints for state and national criminal history background checks.
Following is the Waiver Agreement and FBI Privacy Act Statement. Please complete, sign and date
the Waiver Agreement and FBI Privacy Act Statement form with your application. Your application
will not be deemed as completed without a completed and signed Waiver Agreement and Statement form.
Fingerprinting should be conducted by a person who is appropriately trained to collect fingerprints.
Your local law enforcement agency should be willing to assist you with completing the fingerprints.
Some enforcement agencies offer electronic scanning (Livescan). Please visit our website at
http://www.ksbha.org/departments/licensing/licensingdept.shtml
for a listing of Livescan agencies.
Have at least one form of picture identification for the law enforcement agency to examine.
If you do not utilize a Livescan agency, contact the Board at 785 296-7413 or 888-886-7205 to receive
a fingerprint card or visit https://www.fbi.gov/file-repository/standard-fingerprint-form-fd-258-1.pdf/view
to print a fingerprint card. If printing the card please print on card stock paper.
Please complete the applicant section of the fingerprint card. Ensure the appropriate data fields are
completed prior to submitting the fingerprint card. Be sure to include name (including aliases,
maiden and previous names), complete mailing address, social security number, citizenship, date of
birth, and personal information (sex, race, height, weight, eyes, hair, place of birth). The spaces for
OCA, FBI and MNU numbers can be left blank. Cards with missing or incomplete information will
be rejected and must be resubmitted. Sign the card in front of the law enforcement officer. If you
use Livescan, the agency may have a different form for you to complete.
Make a check or money order (do not send cash) payable to the Kansas State Board of Healing Arts
for $47. A fingerprint card submitted without payment will not be processed.
Any and all resubmissions of fingerprints cards require a $47 as of February 1, 2015 to process.
Resubmitted fingerprint cards will not be processed without payment.
Please complete, sign and return the Waiver Agreement and FBI Privacy Act Statement form with
your application. Your application will not be deemed as complete without a completed and signed
Waiver Agreement and FBI Privacy Act Statement form.
revised 5/4/18 bv
WAIVER AGREEMENT
AND
FBI PRIVACY ACT STATEMENT
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
revised 5-4-18 bv
I hereby authorize (Name of Authorized Recipient) the Kansas State Board of Healing Arts to submit a set of my
fingerprints to the Kansas Bureau of Investigation (KBI) for the purpose of identifying me and accessing and
reviewing Kansas and/or national
criminal history records that may pertain to me. Pursuant to K.S.A. 22-4701 et
seq. and K.S.A. 22-5001, the Authorized Recipient may obtain my criminal history record information for
noncriminal justice purposes. By signing this waiver, it is my intent to authorize release to the above-referenced
Authorized Recipient of any Kansas and/or national criminal history record that may pertain to me. I further
understand that, if applicable, the Authorized Recipient may choose to deny me unsupervised access to children, the
elderly, or individuals with disabilities until the criminal history background check is completed.
I understand that, upon my request, the Authorized Recipient will provide me a copy of the criminal
history background report, received on me, for the purpose to challenge the accuracy and completeness of any
information contained in any such report. I may be afforded a reasonable amount of time to correct or complete
the criminal history record (or decline to do so) before the Authorized Recipient makes a final decision about
my status as an employee, volunteer or contractor, or my eligibility for any pertinent license, certification or
registration, or adoption. See 28 CFR 50.12(b).
I understand that officials receiving the results of the criminal history record check are to use those results only for
authorized purposes and are prohibited from retaining or disseminating such results in violation of federal statute,
regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and
Privacy Compact Council. (See 5 United States Code (USC) 552a(b); 28 USC 534(b); 42 USC 14616, Article IV(c);
28 CFR 20.21(c), 20.33(d), and 906.2(d).)
FBI PRIVACY ACT STATEMENT
Authority:
The FBI's acquisition, preservation, and exchange of information requested by this form is generally authorized
under 28 U.S.C.534. Depending on the nature of your application, supplemental authorities include numerous
Federal statutes, hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/
or orders of the Attorney General of the United States, or other authorized authorities. Examples include, but are not
limited to: 5 U.S.C. 9101; Pub.L. 94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the
requested information is voluntary; however, failure to furnish the information may affect timely completion or
approval of your application.
Social Security Account Number (SSAN).
Your SSAN is needed to keep records accurate because other people may have the same name and birth date.
Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you
whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what
uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify
individuals in agency records.
Principal Purpose:
Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint-
based checks. Your fingerprints and other information contained on (and along with) this form may be submitted to
the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing
the submitted information to available records in order to identify other information that may be pertinent to the
application. During the processing of this application, and for as long hereafter as may be relevant to the activity for
which this application is being submitted, the FBI may disclose any potentially pertinent information to the
requesting agency and/or to the agency conducting the investigation. The FBI may also retain the submitted
information in the FBI's permanent collection of fingerprints and related information, where it will be subject to
comparisons against other submissions received by the FBI. Depending on the nature of your application, the
requesting agency and/or the agency conducting the application investigation may also retain the fingerprints and
other submitted information for other authorized purposes of such agency(ies)
WAIVER AGREEMENT
AND
FBI PRIVACY ACT STATEMENT (Cont.)
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
Routine Uses:
The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may also be
disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and all
applicable routine uses as may be published at any time in the Federal Register, including the routine uses for the FBI
Fingerprint Identification Records System (Justice/FBI-009) and the FBI's Blanket Routine Uses (Justice/FBI-BRU).
Routine uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil
or criminal law enforcement, counterintelligence, national security or public safety matters to which the information
may be relevant; to State and local governmental agencies and nongovernmental entities for application processing as
authorized by Federal and State legislation, executive order, or regulation, including employment, security, licensing,
and adoption checks; and as otherwise authorized by law, treaty, executive order, regulation, or other lawful
authority. If other agencies are involved in processing this application, they may have additional routine uses.
Additional Information:
The requesting agency and/or the agency conducting the application-investigation will provide you additional
information pertinent to the specific circumstances of this application, which may include identification of other
authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in
the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in
which that agency may also maintain your records, including the authorities, purposes, and routine uses for the
system(s).
You may request a copy of your state and/or national criminal history record from the Authorized Recipient for the
purpose of challenging for accuracy and completeness.
Alternatively, you may obtain a copy of your Kansas criminal history record information (CHRI) to review for
accuracy and completeness, by submitting a set of your fingerprints, a letter requesting your criminal history record,
and payment of the appropriate fee to the KBI. For further details, including the current fee, visit the following
Internet website: http://www.kansas.gov/kbi/info/info_brochures.shtml
then find the brochure named “Record
Checks for Non-Criminal Justice Purposes”. Or, to provide official court documents to make a correction you may
write to:
Kansas Bureau of Investigation
Attn: Criminal History Records
1620 SW Tyler
Topeka, Kansas 66612-1837
If a change is made to your Kansas criminal history record due to a challenge, a new copy of your Kansas criminal
history record will be sent to the Authorized Recipient to make a final decision about your status as an employee,
volunteer or contractor, or your eligibility for any pertinent license, certification or registration, or adoption.
To obtain a copy of your national CHRI, also known as the Identity History Summary, for review and challenge
you must submit a set of your fingerprints and the appropriate fee to the FBI. Information regarding this process
may be obtained at: https://www.fbi.gov/services/cjis/identity-history-summary-checks
. Or, you may write to:
FBI CJIS Division
Attn: Criminal History Analysis Team 1
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
RIGHT TO OBTAIN AND CHALLENGE ACCURACY
OF CRIMINAL HISTORY RECORDS
revised 5-4-18 bv
I have ____ OR have not ____ been convicted of a crime.
If convicted, describe the crime(s), the date and location of the crime(s), and the name of the convicting court:
Under penalty of perjury, I hereby declare that I am the person described below, and understand that any falsification
of this statement constitutes a severity level 9, nonperson felony under the provisions of Title 21 Kansas Statutes
Annotated, Section 5903.
I have been provided the Waiver Agreement, FBI Privacy Act Statement, and information how to challenge my
criminal records for accuracy and completeness.
Signature Date
Printed Name Date of Birth
Residential Address City State Zip
WAIVER AGREEMENT
AND
FBI PRIVACY ACT STATEMENT (Cont.)
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
The FBI will forward your challenge to the appropriate contributing agency to verify or correct the entry. Upon receipt
of an official communication directly from that agency, the FBI will make any necessary changes/corrections to your
record in accordance with the information supplied by that agency (see 28 CFR 16.30 through 16.34). The Authorized
Recipient must submit a new set of fingerprints and fee to receive the updated federal criminal history record.
TO BE COMPLETED BY THE FINGERPRINTING AGENCY:
Method of Verifying Identity: Driver's License State Issued ID Card
Military ID Card
State/Branch: ID Number:
Agency Name:
Address:
Telephone: Fax:
Name of Individual Verifying Identity:
AUTHORIZED RECIPIENT: 1. Must maintain original or arrange for KBI to maintain.
2. Must provide a copy to the applicant.
revised 5-4-18 bv
Kansas State Board of Healing Arts
800 SW Jackson Lower Level, Suite A., Topeka, KS 66612
Phone: (785) 296-7413; Fax: (785) 296-0852; Email: KSBHA_Licensing@ks.gov
www.ksbha.org
Revised 9/4/19
CREDIT/DEBIT CARD PAYMENT
AUTHORIZATION FORM
Please enter required information, sign and date at the bottom. Email or Mail form.
____ _____ _____ _____
CARD NUMBER
Verification Code Expiration Date
3-4-digit non-embossed number found on the card signature panel MO YR
_______________ _______ / _______
Name (as it appears on the credit card):
Billing Address:
Street City State Zip
Telephone Number: - -
Payment Amount $ Purpose of Payment:
(e.g. renewal, application)
Applicant/Licensee Name:
I
agree to pay the above amount per the card issuer agreement.
Signature Date
Please Note: The information on this form is considered personal and not subject to disclosure
under the Kansas Open Records Act.
office use only
click to sign
signature
click to edit
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 1 of 8
Full Name
Last name: _______________________________________________________________ Suffix: _______
First name: ____________________________________________________________________________
Middle name: ___________________________________________________________________________
Maiden name (if applicable): _______________________________________________________________
All other names used/identified as: __________________________________________________________
___________________________________________________________ Degree Type M.D. D.O.
Practice Address
Public Access Street:____________________________________________________
Mailings for Medical Board _________________________________________________________
City: _____________________________________________________
State/Province: ____________________________________________
Zip code: ________ Country: _________________________________
Practice phone: _________________ Practice fax: ________________
Alternate phone: _________________ Alternate fax: _______________
Practice email: _____________________________________________
Home Address
Public Access Street:____________________________________________________
Mailings for Medical Board _________________________________________________________
City: _____________________________________________________
State/Province: ____________________________________________
Zip code: ________ Country: _________________________________
Home phone: __________________ Home fax: ___________________
Alternate phone: _________________ Alternate fax: _______________
Home email: ______________________________________________
Identification
Date of birth: ________________ Gender: ______ Birth city: ___________________________________
(mm/dd/yyyy)
Birth state/province: __________________________ Birth country: ________________________________
Social Security number*: _____________ NPI number**: ______________ U.S. Citizen? Yes No
(9 digits) (10 digits)
*Your social security number is required to facilitate reporting to the federal Healthcare Integrity & Protection Data Bank (42 U.S.C.
Sections 1320a-7e(b), 5 U.S.C. Section 552a, and 45 C.F.R. pt. 61) and for accurate identification under the federal and state child support
enforcement law (42 U.S.C. Section 666 and applicable state law). It may also be used for reporting to the National Practitioner Data Bank
(42 U.S.C. Section 11101 and 45 C.F.R. pt. 60) and for other investigative/enforcement purposes in compliance with state laws governing
physician discipline or as otherwise required by state or federal law.
**The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification
Standard. For more information on the NPI, visit http://www.cms.hhs.gov/NationalProvIdentStand/
Indicate your full legal
name and any other
names you have used in
the past. If your name has
changed at any time
during your life and you
are not using FCVS, you
must submit a copy of the
legal document (marriage
certificate, divorce
decree, etc.) supporting
your name change to the
Board.
Please complete all fields
and Indicate which
address you want to use
for public access and at
which address you want
to receive mailings from
the Board. State laws
vary on which address or
phone number is or is not
a matter of public record.
Additionally, many state
boards publish the Public
Access address on their
web sites. You may wish
to contact the
appropriate state
licensing authority to
determine which
information will be a
matter of public record.
If you are not using FCVS,
you must submit one of
the following to the
Board: certified birth
certificate, notarized
copy of your birth
certificate, original valid
passport, or notarized
copy of your current valid
passport. Please check
the state specific
instructions for more
information.
Be sure to list your name
at the top of each
following page.
Uniform Application Core Application
Applicant: Follow the instructions given in the left sidebar of each page.
Send this application to the Kansas State Board of Healing Arts,
800 SW Jackson, Lower Level Suite A, Topeka, KS 66612
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 2 of 8
Applicant Name: ___________________________________________________________________________________________
Medical School
1. Full Name of Medical School: _______________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Attendance dates: From __________ to __________
(mm/yyyy) (mm/yyyy)
Date degree conferred/issued (indicate if not applicable): _________________________________
(mm/dd/yyyy)
Degree received (as stated on diploma): ______________________________________________
(indicate if not applicable)
2. Full Name of Medical School: _______________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Attendance dates: From __________ to __________
(mm/yyyy) (mm/yyyy)
Date degree conferred/issued (indicate if not applicable): _________________________________
(mm/dd/yyyy)
Degree received (as stated on diploma): ______________________________________________
(indicate if not applicable)
Fifth Pathway
I did not participate in a Fifth Pathway program.
Affiliated medical school that awarded the Fifth Pathway Certification
Full Name of Medical School: _______________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Attendance dates: From __________ to __________
(mm/yyyy) (mm/yyyy)
Date degree conferred/issued: __________ Degree (as stated on diploma): _________________
(mm/dd/yyyy)
Hospital or clinic in which you performed the required rotations
Institution name: _________________________________________________________________
Rotation dates: From _____________ to _____________ Certificate date: ___________________
(mm/yyyy) (mm/yyyy) (mm/dd/yyyy)
ECFMG
I do not have an ECFMG certificate.
Certificate number: ____________________ Issue date: _____________________
(mm/dd/yyyy)
List all medical schools
you have attended, even
those from which you did
not graduate, in
chronological order.
Please copy and attach
additional pages if
necessary.
If you are not using FCVS,
you must complete the
Medical Education
Verification form and
send it to all medical
schools you have
attended. Include a copy
of your diploma to which
the medical school must
attach their seal prior to
forwarding it to the
Board.
Additionally, the medical
school must provide the
Board with an official
copy of your transcripts.
If transcripts are not in
English, an original,
certified, and official
English translation is
required.
If you attended a Fifth
Pathway program and are
not using FCVS, you must
complete the Fifth
Pathway Verification
form and send it to your
medical school and to
the institution where you
completed your
rotations. You must
include a copy of your
diploma. The medical
School and institution
must forward all
documentation directly
to the Board.
If ECFMG is applicable
and you are not using
FCVS, contact ECFMG and
have a certified status
report forwarded from
them to the Board. There
is a separate fee for this
report.
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 3 of 8
Applicant Name: ___________________________________________________________________________________________
Postgraduate Training
1. Full Name of Hospital: ____________________________________________________________
Street:_________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code:________
Country: ___________________________ Department/Specialty: ________________________
Affiliated medical school name: _____________________________________________________
Attendance dates: From _________ to _________ Postgraduate year (e.g., 1, 2, 3, etc.): _______
(mm/yyyy) (mm/yyyy)
Chief Resident Internship/Residency Residency Transitional
Fellowship Junior Registrar Residency/Chief Residency
Fellowship/Research Preliminary Senior House Officer Unknown
House Officer Registrar Senior Registrar Unspecified
Internship Research Other: ___________________________
Successfully completed? Yes No In progress; expected completion in _____________
(mm/yyyy)
2. Full Name of Hospital: ____________________________________________________________
Street:_________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code:________
Country: ___________________________ Department/Specialty: ________________________
Affiliated medical school name: _____________________________________________________
Attendance dates: From _________ to _________ Postgraduate year (e.g., 1, 2, 3, etc.): _______
(mm/yyyy) (mm/yyyy)
Chief Resident Internship/Residency Residency Transitional
Fellowship Junior Registrar Residency/Chief Residency
Fellowship/Research Preliminary Senior House Officer Unknown
House Officer Registrar Senior Registrar Unspecified
Internship Research Other: ___________________________
Successfully completed? Yes No In progress; expected completion in _____________
(mm/yyyy)
3. Full Name of Hospital: ____________________________________________________________
Street:_________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code:________
Country: ___________________________ Department/Specialty: ________________________
Affiliated medical school name: _____________________________________________________
Attendance dates: From _________ to _________ Postgraduate year (e.g., 1, 2, 3, etc.): _______
(mm/yyyy) (mm/yyyy)
Chief Resident Internship/Residency Residency Transitional
Fellowship Junior Registrar Residency/Chief Residency
Fellowship/Research Preliminary Senior House Officer Unknown
House Officer Registrar Senior Registrar Unspecified
Internship Research Other: ___________________________
Successfully completed? Yes No In progress; expected completion in _____________
(mm/yyyy)
List all postgraduate
programs you have
attended, even those you
did not complete.
Please copy and attach
additional pages if
necessary.
If you are not using FCVS,
you must complete the
Postgraduate Training
Verification form and
send it to all
postgraduate training
programs you have
attended. You must
submit a copy of your
certificate of program
completion to the Board.
The postgraduate
program must forward all
documentation directly to
the Board.
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 4 of 8
Applicant Name: ___________________________________________________________________________________________
Examination History
Examination Most recent date taken Passed/Failed/Unknown Number of
(mm/yyyy) attempts
FLEX Pre-1985 ___________________ (P) (F) (U) ______
FLEX Component 1 ___________________ (P) (F) (U) ______
FLEX Component 2 ___________________ (P) (F) (U) ______
LMCC Single ___________________ (P) (F) (U) ______
LMCC Part I ___________________ (P) (F) (U) ______
LMCC Part II ___________________ (P) (F) (U) ______
NBME Part I ___________________ (P) (F) (U) ______
NBME Part II ___________________ (P) (F) (U) ______
NBME Part III ___________________ (P) (F) (U) ______
SPEX ___________________ (P) (F) (U) ______
NBOME Part I ___________________ (P) (F) (U) ______
NBOME Part II ___________________ (P) (F) (U) ______
NBOME Part III ___________________ (P) (F) (U) ______
COMLEX-USA Level 1 ___________________ (P) (F) (U) ______
COMLEX-USA Level 2, CE ___________________ (P) (F) (U) ______
COMLEX-USA Level 2, PE ___________________ (P) (F) (U) ______
COMLEX-USA Level 3 ___________________ (P) (F) (U) ______
COMVEX ___________________ (P) (F) (U) ______
USMLE Step I ___________________ (P) (F) (U) ______
USMLE Step II, CS ___________________ (P) (F) (U) ______
USMLE Step II, CK ___________________ (P) (F) (U) ______
USMLE Step III ___________________ (P) (F) (U) ______
State Board Exam
State: _______________ ___________________ (P) (F) (U) ______
State: _______________ ___________________ (P) (F) (U) ______
State: _______________ ___________________ (P) (F) (U) ______
State: _______________ ___________________ (P) (F) (U) ______
State/Province Professional Licensure
1. Practitioner license type: Full license Temporary Training Limited
Doctor of Medicine Nurse Practitioner
Doctor of Osteopathic Medicine Licensed Practical Nurse
Doctor of Dental Surgery Registered Nurse
Doctor of Dental Medicine Physician Assistant
Doctor of Psychology Emergency Medical Technician
Doctor of Podiatric Medicine Other (please specify) ______________________
Doctor of Chiropractic ___________________________________________
State/Province: ______________ License number: _____________ Issue date: ____________
License status: Active Expired In Good Standing
Inactive Limited Probationary
Restricted Retired Revoked Suspended
List the information for
each licensure exam you
have taken, whether U.S.
or international (USMLE,
LLMCC, NBME, etc.).
If you are not using FCVS,
you must contact the
appropriate examination
entity and have them
send a certified transcript
of your scores directly to
the Board.
List all state and
Canadian provinces where
you currently hold or
have ever held any type
of health care related
license. Please copy and
attach additional pages if
necessary.
You must also complete
the Licensure Verification
form and send it to all
states in which you have
held any health care
license or certification.
Some state boards charge
a fee for this information.
The verifying entity must
forward all licensure
documentation to the
Board.
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 5 of 8
Applicant Name: ___________________________________________________________________________________________
2. Practitioner license type: Full license Temporary Training Limited
Doctor of Medicine Nurse Practitioner
Doctor of Osteopathic Medicine Licensed Practical Nurse
Doctor of Dental Surgery Registered Nurse
Doctor of Dental Medicine Physician Assistant
Doctor of Psychology Emergency Medical Technician
Doctor of Podiatric Medicine Other (please specify) ______________________
Doctor of Chiropractic ___________________________________________
State/Province: ______________ License number: _____________ Issue date: ____________
License status: Active Expired In Good Standing
Inactive Limited Probationary
Restricted Retired Revoked Suspended
3. Practitioner license type: Full license Temporary Training Limited
Doctor of Medicine Nurse Practitioner
Doctor of Osteopathic Medicine Licensed Practical Nurse
Doctor of Dental Surgery Registered Nurse
Doctor of Dental Medicine Physician Assistant
Doctor of Psychology Emergency Medical Technician
Doctor of Podiatric Medicine Other (please specify) ______________________
Doctor of Chiropractic ___________________________________________
State/Province: ______________ License number: _____________ Issue date: ____________
License status: Active Expired In Good Standing
Inactive Limited Probationary
Restricted Retired Revoked Suspended
4. Practitioner license type: Full license Temporary Training Limited
Doctor of Medicine Nurse Practitioner
Doctor of Osteopathic Medicine Licensed Practical Nurse
Doctor of Dental Surgery Registered Nurse
Doctor of Dental Medicine Physician Assistant
Doctor of Psychology Emergency Medical Technician
Doctor of Podiatric Medicine Other (please specify) ______________________
Doctor of Chiropractic ___________________________________________
State/Province: ______________ License number: _____________ Issue date: ____________
License status: Active Expired In Good Standing
Inactive Limited Probationary
Restricted Retired Revoked Suspended
5. Practitioner license type: Full license Temporary Training Limited
Doctor of Medicine Nurse Practitioner
Doctor of Osteopathic Medicine Licensed Practical Nurse
Doctor of Dental Surgery Registered Nurse
Doctor of Dental Medicine Physician Assistant
Doctor of Psychology Emergency Medical Technician
Doctor of Podiatric Medicine Other (please specify) ______________________
Doctor of Chiropractic ___________________________________________
State/Province: ______________ License number: _____________ Issue date: ____________
License status: Active Expired In Good Standing
Inactive Limited Probationary
Restricted Retired Revoked Suspended
Please copy and attach
additional pages if
necessary.
click to sign
signature
click to edit
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 6 of 8
Applicant Name: ___________________________________________________________________________________________
Chronology of Activities
1. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
2. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
3. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
List ALL activities
(medical, non-medical,
and postgraduate
training) in chronological
order beginning with
medical school graduation
to the PRESENT date,
indicating month and
year.
*Also list your permanent
or home address for each
non-working time.
If you worked for a
physician-staffing group
or did locum tenens, you
must list all facilities
where you worked and
include complete dates
and addresses.
DO NOT SUBSTITUTE ANY
OTHER RESUME FOR THIS
SECTION.
Copy and attach
additional pages as
necessary.
** Clinical indicates the
percentage of time spent
with patients.
*** Administrative
indicates the percentage
of time spent on
administrative tasks like
paperwork, etc.
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 7 of 8
Applicant Name: ___________________________________________________________________________________________
4. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
5. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
6. Start date: __________________ End date: __________________
(mm/yyyy) (mm/yyyy)
Type of Activity: Health activity (non-working time due to health reasons)
Military service Postgraduate training/education
Seeking employment Vacation Work
Practice/Employment Name or Description of non-working time*: ___________________________
_______________________________________________________________________________
Street: _________________________________________________________________________
City: ______________________________ State/Province: _____________ Zip code: ________
Country: ___________________________ Position: ___________________________________
Department: ________________________________ Clinical**: ____% Administrative***: ____%
Employment Staff Privileges Affiliation
Other (describe your relationship with this institution): _________________________________
Please copy and attach additional pages as necessary.
Copy and attach
additional pages as
necessary.
Applicant: Send this to the Kansas State Board of Healing Arts. Include all fees and required forms. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Core Uniform Application - Page 8 of 8
Applicant Name: ___________________________________________________________________________________________
Malpractice Liability Claims Information
I have not had any malpractice claims or suits made against me.
1. Name of patient involved: __________________________________________________________
In which state, territory, or province did the action take place? _____________________________
Which court*? ___________________________________________________________________
Case number (if applicable) ___________________ Month and year of lawsuit: ______________
Month and year of event precipitating claim: ___________________________________________
Current claim status: Closed (settled) Dismissed (no money paid out)
Open (pending) Other: ____________________
Amount of judgment or settlement: $____________ Amount paid on your behalf: $___________
What is/was your status? Primary Defendant Co-Defendant
Other (specify): __________________________________
Insurance carrier at the time: _______________________________________________________
Please provide specifics in reference to the adverse event, including the allegations and your role
in the event, in the space below. Use another sheet of paper or the back of this form if necessary.
icant Name:
Forms & Affidavit
Complete the forms on the following pages as instructed.
UA Affidavit and Authorization for Release of Information
UA Form #1: Licensure Verification Form
All state-specific forms included with this core application
If you are using FCVS for credentials verification, you do not have to complete forms 2, 3, and 4.
UA Form #2: Medical School Verification
UA Form #3: Postgraduate Training Verification
UA Form #4: Fifth Pathway Verification (if applicable)
Review & Submit
Please review all of your entries prior to submission. Be sure to include all forms, fees, and state addenda.
You are strongly advised to keep a copy for your records.
You must complete this
section to report all
claims or suits for
medical malpractice
made against you. A
claim is any formal or
informal demand for
payment to any person
or organization.
* If private compromise
or settled before
initiation of civil action,
state on this line.
All fields are required to
be answered. Please
have your information
available before starting
this section.
Please copy and attach
additional pages if
necessary.
Applicant: Send this notarized form to the Kansas State Board of Healing Arts. Uniform Application for Physician State Licensure
© July 2014 Federation of State Medical Boards Affidavit and Authorization for Release of Information
I, the undersigned, being duly sworn, hereby certify under oath that I am the person named in this
application, that all statements I have made or shall make with respect thereto are true, that I am the original
and lawful possessor of and person named in the various forms and credentials furnished or to be furnished
with respect to my application, and that all documents, forms, or copies thereof furnished or to be furnished
with respect to my application are strictly true in every aspect.
I acknowledge that I have read and understand the Uniform Application for Physician State Licensure and
have answered all questions contained in the application truthfully and completely. I further acknowledge
that failure on my part to answer questions truthfully and completely may lead to my being prosecuted under
appropriate federal and state laws.
I authorize and request every person, hospital, clinic, government agency (local, state, federal, or foreign),
court, association, institution, or law enforcement agency having custody or control of any documents,
records, and other information pertaining to me to furnish to the Board any such information, including
documents, records regarding charges or complaints filed against me, formal or informal, pending or closed,
or any other pertinent data, and to permit the Board or any of its agents or representatives to inspect and
make copies of such documents, records, and other information in connection with this application.
I hereby release, discharge, and exonerate the Board, its agents or representatives, and any person,
hospital, clinic, government agency (local, state, federal, or foreign), court, association, institution, or law
enforcement agency having custody or control of any documents, records, and other information pertaining
to me of any and all liability of every nature and kind arising out of investigation made by the Board.
I will immediately notify the Board in writing of any changes to the answers to any of the questions contained
in this application if such a change occurs at any time prior to a license to practice medicine being granted to
me by the Board.
I understand my failure to answer questions contained in this application truthfully and completely may lead
to denial, revocation, or other disciplinary sanction of my license or permit to practice medicine.
Notary
State of ______________________________________________, County of __________________________________________________,
I certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this applicant by: (a)
comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph
affixed hereto, and (b) comparing the applicant’s signature made in my presence on this form with the signature on his/her identifying
document.
The statements on this document are subscribed and sworn to before me by the applicant on this ______ day of _________________, 20____.
Notary Public Signature: ____________________________________________________
(NOTARY PUBLIC SEAL)
My Notary Commission Expires: ______________________________________________
Applicant:
This is a separate form
from the FCVS
affidavit and release.
If you are using FCVS,
you must complete
both FCVS and UA
affidavits. Send the
FCVS affidavit to FCVS.
Sign this form with
attached photo in the
presence of a notary
public.
Send this notarized
affidavit to:
Kansas State Board of
Healing Arts
800 SW Jackson, Lower
Level Suite A
Topeka, KS 66612
Applicant Photograph
Securely tape or glue a recent
(less than 6 month old) front-view
2” x 2” passport-type color photo
of yourself in this square.
_________________________________________________________________________________
Applicant’s signature (must be signed in the presence of a notary)
_________________________________________________________________________________
Applicant’s printed last name
_________________________________________________________________________________
Applicant’s printed first name, middle initial, and suffix (e.g., Jr.)
_________________________________________________________________________________
Date of signature (must correspond to date of notarization)
Affidavit and Authorization for Release of Information
Applicant: Follow the instructions in the left sidebar.
Send this notarized form to the Kansas State Board of Healing Arts,
800 SW Jackson, Lower Level Suite A, Topeka, KS 66612
-fold up- -fold up-
After folding the bottom portion upward, bring the new bottom edge to the top edge and fold to fit in a standard envelope.
Licensing Board: Send this completed form to DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
the Kansas State Board of Healing Arts. © July 2014 Federation of State Medical Boards Licensure Verification Form
Section 1: Applicant Information
Last name: ______________________________________________________________ Suffix: ________
First name: ____________________________________________________________________________
Middle name: __________________________________________________________________________
Date of birth: _______________________ Social Security number*: _____________________________
*The social security number is to be used for purposes of identification only and may not be used for any other reason.
Authorization: I am applying for a license to practice medicine. The Board I am applying to requires that
this form be completed by each state or Canadian province in which I hold or have held licenses, whether
now current or not. I authorize the licensing agency of the state/province of _______________________ to
provide any and all information pertaining to license number _________________ to the following Board:
Board name: Kansas State Board of Healing Arts
Mailing address: 800 SW Jackson, Lower Level Suite A
City/State/Zip: Topeka, KS 66612
Applicant signature: _______________________________________________ Date: _______________
Section 2: Licensure Verification
Name of Licensee: ______________________________________________________________________
Last First Middle Suffix
Issuing State Board: _______________________________ License type: ________________________
License number: ____________________ Issue date: ____________ Expiration date: ______________
Is this license current? Yes No If not current, please explain:_______________________________
1. Have formal disciplinary proceedings been initiated against applicant’s license by a disciplinary authority
in your state? Yes No Cannot answer under state law
If yes, please explain: _________________________________________________________________
2. Has the applicant ever been warned, censured, placed on probation, formal consent, reprimand, or in any
other manner disciplined, or has the applicant’s license ever been revoked, suspended, or, in any other
manner, limited by a licensing or disciplinary authority in your state?
Yes No Cannot answer under state law
If yes, please explain: _________________________________________________________________
I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate, and
complete statement of the record of the individual named on this form.
Signature: __________________________________
AFFIX BOARD SEAL HERE Print name: _________________________________
(If no seal is available, this form must be notarized.) Title: ______________________________________
Date: ______________________________________
Email: _____________________________________
Licensure Verification (UA Form #1)
Applicant: Complete this form as instructed in the left sidebar.
Licensing Board: Send this completed form to the address listed in Section 1.
Applicant:
This form must be
used for licensure
verification of each
full, temporary,
training, or limited
license you have held.
This form must be
completed even if you
are using FCVS.
Send this form and any
verification fee to
each state board you
hold a license with.
Copy this form for
multiple licenses.
Licensing Board:
Please complete
Section 2 of this form
and send it to the
Kansas State Board of
Healing Arts at the
address listed in
Section 1.
Alternatively, provide
electronic verification
of licensure to the
Kansas State Board of
Healing Arts.
Medical School: Send this form, transcripts, and sealed DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
diploma to the state board listed in Section 1. © July 2014 Federation of State Medical Boards Medical School Verification Form - Page 1 of 2
Section 1: Applicant Information
Last name: ______________________________________________________________ Suffix: ________
First name: ____________________________________________________________________________
Middle name: __________________________________________________________________________
Name if different when diploma awarded: __________________________________________________
Name of medical school: _______________________________________________________________
Date of birth: _______________________ Social Security number*: _____________________________
*The social security number is to be used for purposes of identification only and may not be used for any other reason.
Waiver for Release of Information: I authorize the medical school listed above to provide any and all
information pertaining to my medical education at that institution to the Board listed below. I request that the
Dean or a designated official complete Section 2 of this form and seal the copy of my diploma (attached),
then return this form, the sealed diploma copy, and a copy of my official transcripts to the Board listed below
at the given address.
Board name: Kansas State Board of Healing Arts
Mailing address: 800 SW Jackson, Lower Level Suite A
City/State/Zip: Topeka, KS 66612
Applicant signature: _______________________________________________ Date: _______________
Section 2: Medical School Verification
Medical school name: ____________________________________________________________________
School name if different when the above applicant attended: ______________________________________
Medical school address (including city, state or province, zip code, and country as applicable):
______________________________________________________________________________________
______________________________________________________________________________________
Hours of undergraduate education required for admission into your school: __________________________
Total weeks of education applicant attended your school: ________________________________________
Applicant’s attendance dates: From ___________________________ to ____________________________
Graduation date: __________________________ Degree: _______________________________________
(indicate N/A if not applicable) (indicate N/A if not applicable)
The questions on the following page apply to unusual circumstances that occurred during any part of the
individual’s medical education. Please check the appropriate response(s) and provide dates and requested
information. “Yes” responses to any of these questions require a copy of explanatory records or a written
explanation. Attach additional pages as necessary.
Medical School Verification (UA Form #2)
Applicant: Complete this form as instructed in the left sidebar.
Dean or Designated Med School Official: Complete as instructed in the left sidebar.
Applicant:
This form is not
needed if you are
using FCVS for
credentials
verification.
Complete Section 1
and fill in your name
at the top of page 2.
Type or print legibly.
Send this form and a
copy of your medical
school diploma to the
current Dean of your
medical school.
Copy this form for
multiple schools.
Dean or Designated
Official:
Please complete
Section 2 of this form
and certify the
enclosed copy of the
above named
applicant’s diploma by
placing your school
seal on it.
Mail the sealed
diploma copy and an
official copy of the
transcripts of the
above named physician
with this form and any
attachments to the
Kansas State Board of
Healing Arts at the
address listed in
Section 1. Do not
mail this form to
FCVS/FSMB.
If transcripts are not in
English, an original,
certified, and official
English translation is
required.
Medical School: Send this form, transcripts, and sealed DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
diploma to the state board listed in Section 1. © July 2014 Federation of State Medical Boards Medical School Verification Form - Page 2 of 2
Applicant Name: ___________________________________________________________________________________________
1. Do the official records for this individual reflect (an) interruption(s) or extension(s) in his/her medical education? Yes No
If yes, please select the reason(s), indicate the dates of the interruption(s) or extension(s), and indicate whether the interruption(s)/
extension(s) was/were approved or unapproved.
From Month/Year To Month/Year Approved Unapproved
Personal/Family ___________________ ___________________
Academic remediation ___________________ ___________________
Health ___________________ ___________________
Financial ___________________ ___________________
Participation in joint degree program ___________________ ___________________
(e.g., MD/PhD)
Participation in non-research special study ___________________ ___________________
(e.g., fellowship, international experience)
Other: ____________________________ ___________________ ___________________
2. Do the official records for this individual reflect that he/she was ever placed on academic or disciplinary probation during his/her
medical education? Yes No
If yes, please select the reason(s) for the probation, indicate the date(s) of placement on and removal from probation, and attach
documentation/information of the circumstances and outcome(s).
From Month/Year To Month/Year
Academic probation ___________________ ___________________
Probation for unprofessional conduct/behavioral reasons ___________________ ___________________
Probation for other reason(s) (please specify): ___________________ ___________________
___________________________________________________________________________________________________
3. Do the official records for this individual reflect that he/she was ever disciplined for unprofessional conduct/behavioral reasons by
the medical school or parent university? Yes No
If yes, please attach documentation/information of the circumstances and outcome(s).
4. Do the official records for this individual reflect that he/she was ever the subject of negative reports for behavioral reasons or an
investigation by the medical school or parent university? Yes No
If yes, please attach documentation/information of the circumstances and outcome(s).
5. Do the official records for this individual reflect that there were ever any limitations or special requirements imposed on the individual
because of questions of academic incompetence, disciplinary problems, or any other reason? Yes No
If yes, please attach documentation/information of the nature of the limitations or special requirements.
I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate, and complete statement of the
record of the individual named on this form.
Signature: ________________________________________________
Print name: _______________________________________________
AFFIX INSTITUTIONAL SEAL HERE Title: _____________________________________________________
(If no seal is available, this form must be notarized.) Date: ____________________________________________________
Phone number: _________________ Fax number: ________________
Email: ____________________________________________________
Program Director or Designated Official: DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
Send this form to the Kansas State Board of Healing Arts. © July 2014 Federation of State Medical Boards Postgraduate Training Verification Form - Page 1 of 2
Section 1: Applicant Information
Last name: ______________________________________________________________ Suffix: ________
First name: ____________________________________________________________________________
Middle name: __________________________________________________________________________
Name if different when diploma awarded: __________________________________________________
Name of postgraduate training program: _____________________________________________________
Date of birth: _______________________ Social Security number*: _____________________________
*The social security number is to be used for purposes of identification only and may not be used for any other reason.
Waiver for Release of Information: I authorize the postgraduate training program listed above to provide
any and all information pertaining to my medical education at that institution to the Board listed below. I
request that the Program Director or a designated official complete Section 2 of this form and send it to the
Board listed below at the given address.
Board name: Kansas State Board of Healing Arts
Mailing address: 800 SW Jackson, Lower Level Suite A
City/State/Zip: Topeka, KS 66612
Applicant signature: _______________________________________________ Date: _______________
Section 2: Postgraduate Training Verification
Institution name: ________________________________________________________________________
Institution address: ______________________________________________________________________
Institution city / state or province / zip code: ___________________________________________________
Affiliated medical school name: _____________________________________________________________
Institution / school name if different when the applicant attended: __________________________________
___________________________________________________________________________________
Postgraduate year (e.g., 1, 2, 3, etc.): _______ Internship Residency Fellowship
Research Chief Residency Other: __________________________________________
Specialty/Subspecialty: ___________________________________________________________________
Attendance dates: From ________________________________ to ________________________________
Successfully completed*? Yes No In progress with expected completion date of ___________
*In each year of training, did the applicant demonstrate sufficient academic and clinical ability to qualify for advancement
without conditional or probationary status to the next year and next progressive level of responsibility in a designated
specialty program?
Accredited by: ACGME AOA LCGME RSC CFPC
RCPSC APPAP None of these
Postgraduate Training Verification (UA Form #3)
Applicant: Complete this form as instructed in the left sidebar.
Program Director or Designated Official: Complete as instructed in the left sidebar.
Applicant:
This form is not
needed if you are
using FCVS for
credentials
verification.
Complete Section 1
and fill in your name
at the top of page 2.
Type or print legibly.
Send this form to the
current Program
Director of your
postgraduate training
program.
Copy this form for
multiple training
programs.
Dean or Designated
Official:
Please complete
Section 2. Report
incomplete years
separately from those
that were completed
successfully. Report
each Internship,
Residency, and
Fellowship separately.
Use one section per
specialty/subspecialty.
Provide a schedule of
rotations if the
specialty/ subspecialty
is
rotating/transitional.
Make copies and
attach additional
pages if necessary.
Send this form to the
Kansas State Board of
Healing Arts at the
address listed in
Section 1 with any
added documentation,
if applicable.
Program Director or Designated Official: DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
Send this form to the Kansas State Board of Healing Arts. © July 2014 Federation of State Medical Boards Postgraduate Training Verification Form - Page 2 of 2
Applicant Name: ___________________________________________________________________________________________
Postgraduate year (e.g., 1, 2, 3, etc.): _______ Internship Residency Fellowship
Research Chief Residency Other: __________________________________________
Specialty/Subspecialty: ___________________________________________________________________
Attendance dates: From ________________________________ to ________________________________
Successfully completed*? Yes No In progress with expected completion date of ___________
*In each year of training, did the applicant demonstrate sufficient academic and clinical ability to qualify for advancement
without conditional or probationary status to the next year and next progressive level of responsibility in a designated
specialty program?
Accredited by: ACGME AOA LCGME RSC CFPC
RCPSC APPAP None of these
Postgraduate year (e.g., 1, 2, 3, etc.): _______ Internship Residency Fellowship
Research Chief Residency Other: __________________________________________
Specialty/Subspecialty: ___________________________________________________________________
Attendance dates: From ________________________________ to ________________________________
Successfully completed*? Yes No In progress with expected completion date of ___________
*In each year of training, did the applicant demonstrate sufficient academic and clinical ability to qualify for advancement
without conditional or probationary status to the next year and next progressive level of responsibility in a designated
specialty program?
Accredited by: ACGME AOA LCGME RSC CFPC
RCPSC APPAP None of these
Unusual Circumstances
1. Did this individual ever take a leave of absence or break from his/her training? Yes No
2. Was this individual ever placed on probation? Yes No
3. Was this individual ever disciplined or placed under investigation? Yes No
4. Were any negative reports for behavioral reasons ever filed by instructors? Yes No
5. Were any limitations or special requirements placed upon this individual Yes No
because of questions of academic incompetence, disciplinary problems,
or any other reason?
I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate, and complete statement of the
record of the individual named on this form.
Signature: ________________________________________________
Print name: _______________________________________________
AFFIX INSTITUTIONAL SEAL HERE Title: _____________________________________________________
(If no seal is available, this form must be notarized.) Date: ____________________________________________________
Phone number: _________________ Fax number: ________________
Email: ____________________________________________________
Please explain any
“Yes” response on an
additional page or in
the blank sidebar area
above.
Program Director or Designated Official: DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
Send this form to the Kansas State Board of Healing Arts. © July 2014 Federation of State Medical Boards Fifth Pathway Verification Form - Page 1 of 2
Section 1: Applicant Information
Last name: ______________________________________________________________ Suffix: ________
First name: ____________________________________________________________________________
Middle name: __________________________________________________________________________
Name if different when certificate awarded: __________________________________________________
Name of medical school: _______________________________________________________________
Date of birth: _______________________ Social Security number*: _____________________________
*The social security number is to be used for purposes of identification only and may not be used for any other reason.
Waiver for Release of Information: I authorize the Program Director or designated official of the Fifth
Pathway program to provide any and all information pertaining to my medical education at that institution to
the Board listed below. I request that the Program Director or a designated official complete Section 2 of this
form and send it to the Board listed below at the given address.
Board name: Kansas State Board of Healing Arts
Mailing address: 800 SW Jackson, Lower Level Suite A
City/State/Zip: Topeka, KS 66612
Applicant signature: _______________________________________________ Date: _______________
Section 2: Fifth Pathway Verification
Institution name: ________________________________________________________________________
Institution address: ______________________________________________________________________
Institution city / state or province / zip code: ___________________________________________________
Institution / school name if different when the applicant attended: __________________________________
Enrollment dates: From ________________________________ to ________________________________
Completed? Yes. Certification date: ____________
No. Withdrawal date: ____________
No. Dismissal date: ____________
In progress. Expected completion date: ____________
If the applicant withdrew or was dismissed, please explain in the space below. Attach additional information
if needed.
Fifth Pathway Verification (UA Form #4)
Applicant: Complete this form as instructed in the left sidebar.
Program Director or Designated Official: Complete as instructed in the left sidebar.
Applicant:
This form is not
needed if you are
using FCVS for
credentials
verification.
Complete Section 1
and fill in your name
at the top of page 2.
Type or print legibly.
Send this form to your
Fifth Pathway
director.
Program Director or
Designated Official:
Please complete all of
Section 2. Send this
form to the Kansas
State Board of Healing
Arts at the address
listed in Section 1 with
any added
documentation, if
applicable.
Program Director or Designated Official: DO NOT SEND THIS FORM TO FCVS/FSMB. Uniform Application for Physician State Licensure
Send this form to the Kansas State Board of Healing Arts. © July 2014 Federation of State Medical Boards Fifth Pathway Verification Form - Page 2 of 2
Applicant Name: ___________________________________________________________________________________________
Type of Clinical Rotation From To Number of Weeks Credit
__________________________________ ____________ ____________ _____
__________________________________ ____________ ____________ _____
__________________________________ ____________ ____________ _____
__________________________________ ____________ ____________ _____
Unusual Circumstances
1. Did this individual ever take a leave of absence or break from his/her training? Yes No
2. Was this individual ever placed on probation? Yes No
3. Was this individual ever disciplined or placed under investigation? Yes No
4. Were any negative reports for behavioral reasons ever filed by instructors? Yes No
5. Were any limitations or special requirements placed upon this individual Yes No
because of questions of academic incompetence, disciplinary problems,
or any other reason?
Please explain any “Yes” response in the blank space below. Attach additional information if needed.
I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate, and complete statement of the
record of the individual named on this form.
Signature: ________________________________________________
Print name: _______________________________________________
AFFIX INSTITUTIONAL SEAL HERE Title: _____________________________________________________
(If no seal is available, this form must be notarized.) Date: ____________________________________________________
Phone number: _________________ Fax number: ________________
Email: ____________________________________________________
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