Fillable License Information & Checklist Application for a Postgraduate (California)

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License Information & Checklist Application for a Postgraduate (California)

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Medical Board of California
Application for a Postgraduate Training
License Information & Checklist
Licensing Program
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815-5401
Phone: (916) 263-2382
Fax: (916) 263-2487
www.mbc.ca.gov
POSTGRADUATE TRAINING LICENSE INFORMATION
A postgraduate training license (PTL) must be obtained
within 180 days after enrollment in an Accreditation
Committee for Graduate Medical Education (ACGME) accredited postgraduate training program in California.
The PTL will be valid until 90 days after a resident has successfully completed 36 months of pos
tgraduate
training at which point a full and unrestricted physician’s and surgeon’s certificate must be obtained in order to
continue clinical services in California.
The PTL will be valid until 90 days after a resident has successfully completed 36 months
of accredited training
if the resident is currently enrolled in an ACGME-
accredited training program in California. If a resident has
successfully completed a three year residency and is not currently enrolled in an ACGME accredited program,
the resident would need to cease all clinical services in California until a physician’s and surgeon’s l
icense is
issued.
MINIMUM REQUIREMENTS
To be eligible for a PTL, the applicant must be enrolled in an approved ACGME accredited postgraduate
training program in California.
Applicants must have received all of their medical school education from and graduated from a:
1)
U.S. or Canadian medical school accredited by the Liaison Committee for Medical Education (LCME),
the Committee on Accreditation of Canadian Medical Schools.
http://lcme.org/directory/accredited-u-s
-
programs/
- OR -
2)
A foreign medical school which has been evaluated by the Educational Commission for Foreign Medical
Graduates (ECFMG) or one of the ECFMG authorized foreign medical school accreditation agencies and
deemed to meet the minimum requirements substantially equivalent to the requirements of medical
schools accredited by the Liaison Committee on Medical Education, the Committee on Accreditation of
Canadian Medical Schools, or the Commission on Osteopathic College Accreditatio
n.
The foreign medical school is listed on the World Federation for Medical Education (WFME) and the
Foundation for Advancement of International Medical Education and Research (FAIMER) World
Directory of Medical Schools joint directory, or the World Directory of Medical Schools.
https://search.wdoms.org/
- OR -
3)
A foreign medical school that has been approved by the Medical Board of California (Board).
http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx
Disclosure of a United States Social Security Number (SSN) or an Individual Taxpayer Identification Number
(ITIN) is mandatory prior to the issuance of a PTL. Section 30 of the Business and Professions Code
authorizes collection of an SSN or ITIN. Section 31(e) of the Business and Professions Code allows the
State Board of Equalization and the Franchise Tax Board to share taxpayer information with the Board.
To meet the minimum examination requirement for a PTL, you must have taken and passed Steps 1 and
2CK of the United States Medical Licensing Examination (USMLE) or all parts of the Licentiate of the Medical
Council of Canada (LMCC) examination per Title 16 of the Cali
fornia Code of Regulations section 1328.
Certification by the Educational Co
mmission
for Foreign Medical Graduates (ECFMG) is required if the
applicant graduated from a foreign medical school. To obtain further information regarding ECFMG
Certification
, please refer to their website at http://www.ecfmg.org/.
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs PTL App Info (Rev 02/20)
GENERAL INFORMATION
Fingerprints: Applicants who reside in California must complete the electronic Live Scan fingerprint
process. The Request for Live Scan Service form may be obtained from the Board’s website. Please refer
to the following website for Live Scan facilities in Californi
a:
https://oag.ca.gov/fingerprints/locations
.
Applicants residing outside
of
California must submit two completed fingerprint cards or if visiting California,
you may have your fingerprints completed electronically at a California Live Scan facility.
Criminal Records Check from both the California Department of Justice and the Federal Bureau of
Investigation must be received prior to the issuance of a PTL.
Grounds for Denial: Each applicant’s credentials for licensure in California are reviewed on an individual
basis. The Board has the authority to deny licensure based upon an applicant’s act of dishonesty,
unprofessional conduct, conviction of a crime, discipline by a licensing board in or outside of California, or
inability to practice medicine safely.
The Federation Credentials Verification Service (FCVS): The FCVS is operated by the Federation of
State Medical Boards. The Board offers this link to FCVS as a convenience to applicants. Individuals may
learn more about FCVS at
: http://www.fsmb.org/licensure/fcvs/.
The Board does not mandate the use the FCVS
. FCVS is NOT a requirement for completing a
PTL
application. Applicants will be required to complete the Board’s application and provide all necessary
supporting documentation. As part of the application, applicants may request FCVS to submit
their
Medical
Professional Information Profile
directly to th
e Board. The Board will review the information provided along
with the application and determine on an individual basis the items that will be accepted from FCVS.
NotaryCam: NotaryCam is a company that provides an online notary service that is valid in California and
may be used on the Board’s application forms.
The Board does not
https://www.notarycam.com/
mandate the use of this online service
.
The Board is providing this information as a convenience to applicants. Applicants may obtain further
information regarding this online notary service at:
.
Certified Electronic Diploma (CeDiploma®): CeCredential Trust® is a company that provides an
alternative to a paper diploma and is accepted by the Board. The Board does not mandate that applicants
use this online service. If a CeDiploma® was not issued by the medical school, please contact the school
directly. The Board is providing this information as a convenience to applicants. Applicants may obtain
further information regarding t his electronic diploma service at: https://www.cecredentialtrust.com/.
APPLICATION CHECKLIST
Listed below are the minimum application and supporting materials required for a medical school
graduate to obtain a PTL. This list is not all-inclusive as additional items may be necessary based on
responses provided on the application or information obtained from other entities.
Application Information for a Postgraduate Training License – Page 2
Application, Fees, and Fingerprints
Postgraduate Training
License Application,
Forms PTL1-PTL5
Complete all fields, answer all questions and have the
application notarized.
All five pages must be submitted together.
Application Fee - $491.00
The application fee includes the required fingerprint processing fee. The
fees are non-refundable.
APPLICATION CHECKLIST (Continued)
Application, Fees, and Fingerprints (Continued)
Fingerprints:
Live Scan Form (CA Only)
- OR -
Two (2) Fingerprint Cards
Applicants who reside in California must complete the electronic Live Scan
fingerprint process. They will need to use the Request for Live Scan Service
form available on the Board’s website. Include a copy of the completed
form with the application.
Applicants residing outside of California must submit two completed
fingerprint cards or
have fingerprints completed at a California Live Scan
facility. Fingerprint cards will be mailed once the Board receives an
application and appropriate processing fees.
All personal data must be
completed on the fingerprint
cards or the cards will be returned for
completion.
Criminal Records Check from both the California Department of Justice and
the Federal Bureau of Investigation must be received prior to the issuance
of a PTL.
Examination Documentation
ECFMG Certification
A Certification Status Report from the ECFMG is required to verify the
Status Report:
certification is valid. Applicants may obtain further information from its
(International Medical website at
http://www.ecfmg.org/.
The ECFMG must mail the
School Graduates Only) Certification Status Report directly to the Board to be acceptable.
Official Examination
Scores from the
appropriate
examination entity:
USMLE or LMCC
Certificate of Medical
Education, Form MED
Official examination history reports must be requested from the appropriate
examination agency. Official examination history reports may be requested
from the following websites:
USMLE - https://www.fsmb.org/transcripts/
(Only an electronic submission will
be accepted by the Board.)
LMCC - http://www.mcc.ca/
Each examination agency must submit an original, official
examination history report directly to the Board to be acceptable.
Medical Education Documentation
A Certificate of Medical Education (Form MED), is required from each
medical school attended. Complete the applicant information at the top of
the form and mail it to the medical school. The form will need to be
completed, signed and dated by the school official and affixed with the
official medical
school seal. Any fields or questions left unanswered will
require completion of a new form. The form must be submitted directly
from the medical school to the Board to be acceptable.
Official Medical School
Transcript
Certified Copy of Medical
School Diploma
An original official medical school transcript and translation (if not in
English), prepared on university letterhead affixed with the signature of the
dean or registrar and the medical school seal, documenting all of the basic
science and clinical courses
completed during the medical curriculum is
required.
A transcript is required from each medical school attended.
The transcript must be submitted directly from the medical school to
the Board to be acceptable.
A certified copy of the medical school diploma is required. The certified
copy must have the original signature of the dean or registrar of the medical
school, be affixed with the official medical school seal, and include a
statement attesting that the c
opy is a true and correct copy of the original.
If applicable, a CeDiploma® will be accepted by the Board. The certified
copy of the diploma must be submitted
directly from the medical
school to the Board to be acceptable.
Application Information for a Postgraduate Training License – Page 3
APPLICATION CHECKLIST (Continued)
Postgraduate Training Documentation
Certificate of Completion
This form is only necessary if there is prior postgraduate training.
A
of ACGME/RCPSC/CFPC
Certificate of Completion of ACGME/RCPSC/CFPC Postgraduate Training
Postgraduate Training,
(Form PTA-PTB) is required to verify the completion of the any ACGME,
Form PTA-PTB
RCPSC, or CFPC accredited postgraduate training required for licensure.
(If applicable)
The form must
be submitted to each postgraduate training program for
completion. A “yes” response to any of the questions on Form PTA requires
a signed and dated letter of explanation from the current program director.
The completed form must be submitted directly from the program to
the Board to be acceptable. Any letters of explanation must be
provided on program letterhead, signed by the program director and
submitted directly to the Board.
Postgraduate Training
Proof of enrollment in a Board approved ACGME accredited postgraduate
License Enrollment Form,
training program is required. Complete the applicant information and
Form EF
submit the form to the current training program for completion. The current
program director must provide all of the required information and responses
on the form, sign and date the form, and affix with the program seal. If a
program seal is not available, the program director must sign in the
presence of a notary and the notary seal must be affixed. The Form EF
must be submitted directly from the program to the Board to be
acceptable.
Other Items
Timeline of Activities,
Provide the Board with a written chronological description of all professional
Form TOA
and non-professional activities, from the date of graduation, with no gaps.
(If the applicant has
If the applicant has completed any externships, observerships, or volunteer
graduated within the last 6
activities in California, please include a detailed description of the duties
months, this form is not
and responsibilities along with the location and name of the supervising
needed)
physician.
Submit the signed
and dated Timeline of Activities form directly to the
Board.
Explanation For
This form may be used to provide a detailed written explanation for a “yes”
Application Question,
response to a question on the Board’s application. A separate form is
Form EXP
required for each question.
(If applicable)
License Verification
License verification is required from each state or Canadian province in
(If applicable)
which an applicant holds or has held a license to practice medicine.
Verification of temporary, training, or provisional license(s) are not
required.
The official license verification must be submitted directly from the
licensing authority to the Board.
NOTE
The Board must be notified within 30 days if the trainee transfers to another California postgraduate training
program. The program director must complete
a Program Status Update/Change Form (Form PSU1-PSU2)
,
if the trainee moves, or transfers to another program, is terminated, resigns, or takes a leave of absence.
Application Information for a Postgraduate Training License – Page 4
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Completed 20 December 2020

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