Fillable PHYSICIAN APPLICATION CHECKLIST (State of Nevada, Department of Information Technology)

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PHYSICIAN APPLICATION CHECKLIST (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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Revised 1/12/2021
PHYSICIAN
APPLICATION CHECKLIST
TO BE RETURNED DIRECTLY TO BOARD OFFICE BY APPLICANT
Revised 1/12/2021
____ a. APPLICATION:
Properly completed, signed and notarized application, including Applicant Responsibility statement;
Recent passport quality photograph (at least 2”x 2”) attached to application;
Appropriate explanations and copies of all pertinent documentation must be attached for affirmative responses
to questions numbered 8, 9, 10, 11, 12, 12a, 13, 14, 19, 27, 28, 29, 30, 31, 32, and 33;
Release form, signed and notarized (Form A);
____ b. FEES:
Proper application, registration, AND criminal background investigation fees – cashier’s check or money order made
payable to Nevada State Board of Medical Examiners (NSBME) or by credit card as instructed. Credit cards will
only be accepted by receipt of the signed credit card authorization form.
Note: Application and criminal background investigation fees are non-refundable;
____ c. IDENTITY (Identity documents will be returned to you via secured mail.):
1. U.S. born citizens: Original or Certified Birth Certificate that bears an original seal or stamp of the issuing
agency (notarized copies are not acceptable).
2. Foreign-born citizens: Original Certificate of Naturalization or current U.S. Passport.
3a. Non-U.S. citizens (with legal status):
Copy of both sides of Alien Registration or Employment Authorization card, or Visa; and
Copy of foreign passport.
3b. Non-U.S. citizens (otherwise):
Individual Taxpayer Identification Number (ITIN) and original ITIN assignment letter from the IRS
Supporting documentation of identity also required, e.g., Passport, or USCIS, US Military, or
US State I.D.
Note: FCVS verification packet may provide appropriate “Seal verified” Identity documentation.
____ d. SELF-QUERY VERIFICATION:
Self-query response from the National Practitioner Data Bank (NPDB) - see enclosed “Instructions” page. The
NPDB will send the report directly to you and you will forward the final report to the Board office;
____ e. SUPPLEMENTARY FORMS:
FORM B: ONLY if you have answered affirmatively to either of the two malpractice questions on the
application; Also include:
o Copy of the legal Complaint
o Copy of the Settlement and/or filed Dismissal
FORM C: ONLY if applying for a license by Endorsement (Endorsement is NOT reciprocity – please refer
to the “License Description” page of your application for clarification.);
FORM D: ONLY if applying for an unlimited license as a Resident currently in a program – you must have
passed all steps of United States Medical Licensing Examination (USMLE) and completed at least 24 months
of ACGME accredited progressive postgraduate training in the United States or Canada;
____ f. BOARD CERTIFICATION:
Copy of American Board of Medical Specialties (ABMS) Board certification certificate(s), copy of ABMS
Board re-certification certificate(s);
Note: FCVS packet may provide a copy of your ABMS certification(s);
If you hold “lifetime or historical” ABMS Board certification, submit a notarized statement agreeing to
maintain your specific Board certification for the duration of your licensure in the state of Nevada;
____ g. CONTINUING EDUCATION:
Proof of 4 hours bioterrorism AMA Category 1 continuing medical education (CME) relating to the medical
consequences of an act of terrorism that involves the use of a weapon of mass destruction. Search for an online
course “AMA Category 1 bioterrorism continuing medical education” or take a classroom course;
Proof of 2 hours AMA Category 1 continuing medical education (CME) in clinically-based suicide prevention
and awareness;
____ h. FINGERPRINTING:
Once the application and criminal background investigation fee have been received, a fingerprint card and
instructions will be mailed to you. The fingerprint card you receive from the Board contains the necessary
account numbers required for processing. The completed card must be returned to the Board as well as the
signed Civil Applicant Waiver (included in your application package) prior to licensure. Note: Receipt of the
Criminal history background results will not delay licensure.
PHYSICIAN
APPLICATION CHECKLIST
DIRECT SOURCE VERIFICATIONS TO BE SOLICITED BY APPLICANT
FOR DIRECT RETURN BY THE VERIFYING INSTITUTION TO BOARD OFFICE
Verifying agencies may charge a fee. Do not provide pre-stamped or pre-addressed envelopes for direct source verifications.
* Federation Credentials Verification Service (FCVS) packet may verify these documents.
Disclaimer: Per Nevada Revised Statute 630.173(2), the Board has the right to consider information for any malpractice history
or derogatory hospital privilege history that is more than 10 years old.
_____
*
a. MEDICAL SCHOOL:
Verification of Medical Education (Form 1) to be completed by medical school(s);
Official transcripts from all schools where professional medical instruction was received
(if transcripts are not in English, a certified original and official English translation is required);
_____
*
b. POSTGRADUATE TRAINING PROGRAM:
Certificate of Completion of Progressive Postgraduate Training (Form 2) to be completed by all
institutions where any training occurred (internship, residency, fellowship and research fellowship);
_____
*
c. RESIDENT APPLYING AFTER COMPLETION OF 24 MONTHS OF TRAINING:
Verification of postgraduate training Form 2 showing current postgraduate year as “in progress”;
Once postgraduate training program has been completed, proof of satisfactory completion of
progressive postgraduate training (follow-up verification of postgraduate training Form 2) submitted
directly to the Board from the program within 60 days after the scheduled completion of the program;
Residents applying after completion of 24 months of training must meet Nevada’s USMLE
requirements (see Examination information below);
_____
*
d. EXAMINATION:
Certification of National Board, FLEX, USMLE, LMCC or SPEX scores - see “Instructions” page.
For State written examination certification in combination with current ABMS certification, see
“Instructions” page;
Note: In the state of Nevada, for United States Medical Licensing Examination (USMLE) a
person must pass Steps I, II and III of the USMLE within 7 years after the date on which the
person first passes any step of the USMLE and a person is limited to a combined maximum of
9 attempts to pass steps I, II, and III and no more than 3 attempts at step III of the USMLE.
Certification status report from the Educational Commission for Foreign Medical Graduates
(ECFMG) – see “Instructions” page;
_____
*
e. BOARD CERTIFICATION:
Verification of ABMS Board certification, if applying via state written exam/board certification;
Verification of ABMS Board certification, if eligible to apply based on NRS 630.160 (2)(c) or (2)(d);
_____
f. LICENSE VERIFICATIONS:
License verification (Form 3) from all states where you are currently licensed or have ever been licensed
(this does not include training licenses or temporary permits);
_____
g. MALPRACTICE INSURANCE CARRIER VERIFICATIONS:
Malpractice insurance carrier verification (Form 4) to be completed by appropriate entity and returned
directly by the verifying institution to the Board office and must include the loss history report for any
and all malpractice cases that occurred within the past 10 years (see Disclaimer below);
_____
h. HOSPITAL VERIFICATIONS:
Verification of hospital privileges (Form 5) to be completed by appropriate entity and returned directly
by the verifying institution to the Board office if you answered affirmatively to having had any
disciplinary issues regarding your hospital privileges within the past 10 years (see Disclaimer below);
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PHYSICIAN APPLICATION CHECKLIST (State of Nevada, Department of Information Technology)

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Completed 26 October 2021

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