Fill - Free fillable Require Instruct App For Physician 11.18R (Hawaii) PDF form

REQUIREMENTS AND INSTRUCTIONS -

PHYSICIAN (MD License) or

PHYSICIAN employed by Hawaii State or County Government

(MDG License)

Access this form via website at:

cca.hawaii.gov/pvl

This application is to be used by physicians seeking a regular physicians (MD) license or limited and temporary (MDG) license for Hawaii

State or County government employment. Physicians seeking a limited and temporary license for education/teaching, sponsorship, or

emergency/shortage are directed to use the "Limited and Temporary License - Physician" application form.

**********************************************************************************************************************

MD LICENSE This is a full, regular license that expires on January 31 of each even-numbered year.

REQUIREMENTS

MD LICENSE

(U.S. and Canadian

Medical Graduates)

U.S. and Canadian Medical School Graduates

MD degree from an LCME-accredited medical school in the U.S. or Canada.

•

One year of residency training in an ACGME-accredited program in the U.S. OR

One year of residency training in a RCPSC or CFPC-accredited program in Canada.

Satisfactory completion of the NBME, FLEX, USMLE, MCCQE (Qualifying Exam of LMCC) OR

•

Satisfactory completion, prior to 2000, of an acceptable combination of the NBME, FLEX and USMLE OR

Satisfactory completion of the SPEX, provided that the physician was licensed in another state by virtue

of having passed a state-produced examination.

Items/documents required when applying:

•

Application form

•

Fees

Verification of licensure

Hospital Form

Evidence of MD degree

Evidence of residency training

National Practitioner Data Bank report

AMA Profile

Federation report

Examination scores

REQUIREMENTS

MD LICENSE

(Foreign Medical

Graduates)

Foreign Medical School Graduates (FMG)

There are two alternative pathways for FMG applicants.

Those who served in an ACGME-accredited residency program in the U.S., or an RCPSC or CFPC-accredited residency

program in Canada, should refer to the first pathway for the licensure requirements.

All other applicants should refer to the second pathway for the licensure requirements.

(CONTINUED ON PAGE 2)

MD-02 1118R

REQUIREMENTS

MD LICENSE

(Foreign Medical

Graduates)

(Cont'd.)

FIRST PATHWAY:

•

MD degree from a foreign medical school.

•

Two years of residency training in a ACGME-accredited program in the U.S. OR

Satisfactory completion of the NBME, FLEX, USMLE, MCCQE (Qualifying exam of LMCC) OR

ECFMG Certificate or MCCEE (Evaluating Exam of LMCC) OR

Two years of residency training in an RCPSC or CFPC-accredited program in Canada

Satisfactory completion, prior to 2000, of an acceptable combination of the NBME, FLEX and USMLE OR

Satisfactory completion of the SPEX, provided that the physician was licensed in another state by virtue

of having passed a state-produced examination.

Fifth Pathway Certificate.

Items/documents required when applying:

•

Application form

Fees

•

Verification of licensure

Hospital Form

Evidence of MD degree

Evidence of residency training

Verification of ECFMG or Fifth Pathway Certificate or MCCEE

National Practitioner Data Bank report

AMA Profile

Federation report

Examination scores

SECOND PATHWAY:

•

MD degree from a foreign medical school.

•

Three years of medical training or experience in a hospital approved by the AMA's Council on Medical

Education and Hospitals for internship or residency.

Satisfactory completion of the FLEX or USMLE OR

Satisfactory completion, prior to 2000, of an acceptable combination of these examinations.

Passed the VISA Qualifying Examination of Educational Commission for Foreign Medical Graduates prior

to 1984.

Items/documents required when applying:

(CONTINUED ON PAGE 3)

-2-

•

Application form

Fees

Verification of licensure

Hospital Form

REQUIREMENTS

MD LICENSE

(Foreign Medical

Graduates)

(Cont'd.)

•

**********************************************************************************************************************

Evidence of MD degree

Evidence of medical training or experience approved by the AMA's Council on Medical Education and

Verification of VISA qualifying examination of the ECFMG prior to 1984

National Practitioner Data Bank report

AMA Profile

Federation report

•

Examination scores

MDG LICENSE

This is a limited and temporary license for government employment that expires on January 31 each year.

REQUIREMENTS

MDG LICENSE

(U.S. and Canadian

Medical Graduates)

U.S. and Canadian Medical School Graduates

•

MD degree from an LCME-accredited medical school in the U.S. or Canada.

•

One year of residency training in an ACGME-accredited program in the U.S. OR

One year of residency training in an RCPSC or CFPC-accredited program in Canada.

Licensed by written examination in another state or U.S. territory.

•

Items/documents required when applying:

•

Application form

•

Fees

Verification of licensure

Hospital Form

Evidence of MD degree

Evidence of residency training

Verification of state or county government employment

National Practitioner Data Bank report

AMA Profile

Federation report

Examination scores

REQUIREMENTS

MDG LICENSE

(Foreign Medical

Graduates)

Foreign Medical School Graduates (FMG)

•

MD degree from a foreign medical school.

•

Two years of residency training in an ACGME-accredited program in the U.S. OR

Two years of residency training in an RCPSE or CFPC-accredited program in Canada

ECFMG Certificate OR

Fifth Pathway Certificate.

Licensed by written examination in another state or U.S. territory.

-3-

(CONTINUED ON PAGE 4)

Hospitals for internship or residency

REQUIREMENTS

MDG LICENSE

(Foreign Medical

Graduates)

(Cont'd.)

Items/documents required when applying:

•

Application form

•

Fees

Verification of licensure

Hospital Form

Evidence of MD degree

Evidence of residency training

Verification of ECFMG or Fifth Pathway Certificate

Verification of state or county government employment

National Practitioner Data Bank report

AMA Profile

Federation report

Examination scores

INSTRUCTIONS FOR FILING AN APPLICATION AND SUBMITTING THE REQUIRED ITEMS

Complete on-line fillable application or print legibly in dark ink. Most items on the form are self-explanatory. Those that need explanation are

discussed below.

SOCIAL SECURITY

NUMBER

Your Social Security Number is used to verify your identity for licensing purposes and for compliance with the below

laws. For a license to be issued, you must provide your Social Security Number or your application will be

deemed deficient and will not be processed further.

The following laws require that you furnish your Social Security Number to our agency:

FEDERAL LAWS:

42 U.S.C.A. §666(a)(13) requires the Social Security Number of any applicant for a professional license or

occupational license be recorded on the application for license; and

If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security

Number as part of the mandatory reporting we must do to the Healthcare Integrity and Protection Data Bank

(HIPDB), of any final adverse licensing action against a licensed health care practitioner.

HAWAII REVISED STATUTES ("HRS"):

§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational

license be recorded on the application for license; and

§436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security Number if

the licensing authority is authorized by federal law to require the disclosure (and by the federal cites shown above,

we are authorized to require the Social Security Number).

FEES ATTACH a check payable to: COMMERCE AND CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a

U.S. financial institution.)

MD License issued between February 1, even-numbered year,

to January 31, odd-numbered year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $392

(Application fee - $50**, License - $97, Compliance Resolution Fund - $148, 1/2 Renewal - $97)

MD License issued between February 1, odd-numbered year,

to January 31, even-numbered year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $221*

(Application fee - $50**, License - $97, Compliance Resolution Fund - $74)

MDG License . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $164***

(Application - $25**, License - $65, Compliance Resolution Fund - $74)

* Subject to renewal January 31, even-numbered years - regardless of issue date.

** Application fee is not refundable.

*** Subject to renewal January 31, annually.

(CONTINUED ON PAGE 5)

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FEES

(Cont'd.)

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the

payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for

your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required

licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service

charge shall be assessed for payments that are dishonored for any reason.

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16,

Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing

must be directed to the agency that denied your application, and must be made within 60 days of notification that your

application for a license has been denied.

QUESTIONS In the event the response to any of the questions numbered 6 through 15 is "YES", please file a typewritten or a

legible handwritten detailed explanation and supplemental information as directed on the application.

EVIDENCE OF

MD DEGREE

ATTACH a copy of your MD diploma, medical school transcripts or letter from the dean of the medical school, which

provides the date of your graduation from medical school. If your documents are in a foreign language, an accurate

translation must be attached from the medical school or other organization that provides translating services.

Translations may not be provided by the applicant.

EVIDENCE OF

RESIDENCY

TRAINING

The following applicants are to provide evidence of residency training:

•

All U.S. and Canadian medical school graduates

•

FMG applicants for MD license through 1st pathway

FMG applicants for MDG license

ATTACH a copy of your residency certificate or letter from the program director of your residency training, which

provides the dates of successful completion of residency training.

EVIDENCE OF

TRAINING OR

EXPERIENCE

FMG applicants for MD license through 2nd pathway are to provide evidence of medical training or

experience:

ARRANGE to have the hospital in which you received at least 3 years of medical training or experience send evidence

of this directly to the Hawaii Medical Board (HMB). To do this, contact the hospital and request that they provide:

•

hospital's name and address

dates of your training or experience

verification that the hospital has been approved by the AMA's Council on Medical Education and Hospitals for

internship or residency

VERIFICATION

OF LICENSE

On the application, list all the licenses you hold or held, including those for residency training or locum tenens.

ARRANGE to have verification of licensure sent directly to the HMB. To do this, contact all the jurisdictions that you

are/were licensed in and request that they send a verification of licensure directly to the HMB.

HOSPITAL FORM On the application, list all the hospitals where (in the last 3 years) you:

•

have held or applied for consultation, teaching appointments, privileges or locum tenens positions; or

serve/served in an internship or residency program.

ARRANGE to have the hospital forms sent directly to the HMB. To do this, send copies of the "Hospital" form

(MD-08) to the hospitals and request that they send the forms directly to the HMB.

(CONTINUED ON PAGE 6)

-5-

SYNOPSIS OF

MEDICAL PRACTICE

Provide a synopsis of your medical practice from the time you completed residency training to

the present. If there have been breaks in your practice, please provide an explanation. Attach additional sheets if

necessary.

EVIDENCE OF ECFMG

OR FIFTH PATHWAY

CERTIFICATE

The following applicants are to provide evidence of the ECFMG or Fifth Pathway Certificate:

•

FMG applicants for MD license through 1st pathway.

FMG applicants for MDG license.

ECFMG Certificate

ARRANGE to have the Status Report of ECFMG Certification sent directly to the HMB. To do this, contact ECFMG at

(215) 386-5900 or go to: www.ecfmg.org.

Fifth Pathway

ARRANGE to have verification of completion of your AMA Fifth Pathway sent directly to the HMB. To do this,

contact AMA at: www.ama-assn.org or call (312) 464-5199 for assistance.

VISA QUALIFYING

EXAMINATION

FMG applicants for MD license through 2nd pathway are to provide evidence of medical training or

experience:

ARRANGE to have ECFMG send the score of the VISA qualifying examination passed prior to 1984, sent directly to

the HMB. To do this, contact ECFMG at (215) 386-5900 or go to: www.ecfmg.org.

VERIFICATION

GOVERNMENT

EMPLOYMENT

All applicants for MDG license are to provide verification of government employment:

ATTACH a statement from an official of the state or county government agency confirming employment. This

license is only valid for and while in the employment of the government agency and must be renewed annually.

NATIONAL

PRACTITIONER

DATA BANK REPORT

ATTACH the original "SELF-QUERY RESPONSE" report from the National Practitioner Data Bank (NPDB). To obtain the

report, go to the NPDB-HIPDB website at: www.npdb.hrsa.gov and click on Perform a Self-Query. If you are

unable to go on-line, call NPDB-HIPDB at 1-800-767-6732 for assistance.

The NPDB is now making your NPDB report available for download. The HMB will accept either the ORIGINAL hard

copy that is mailed to you or an electronic version of the report. To send the electronic version, please, save the

report as a .pdf file, attach it to the ORIGINAL email from NPDB and email to: medical@dcca.hawaii.gov.

AMA PROFILE ARRANGE to have the American Medical Association (AMA) Profile sent directly to the HMB by going to the AMA

website at: https://commerce.ama-assn.org/store/. If you are unable to go on-line, call AMA at (312) 464-5199 for

assistance. An AMA Profile is required of all physicians, including those who are not members of AMA.

(CONTINUED ON PAGE 7)

-6-

FEDERATION

REPORT

Applicants who passed the NBME, state examination, MCCQE or MCCEE:

ARRANGE to have the Federation Discipline Report sent directly to the Hawaii Medical Board (HMB). Email the

"Federation Discipline Report" form (MD-07) to the Federation of State Medical Boards (Federation -

boardinquiry@fsmb.org) and request that they send the form directly to the HMB.

Applicants who passed the USMLE, FLEX, SPEX examination:

ARRANGE to have the Federation send an "Examination and Board Action History Report" (EBAHR) directly to the

HMB. To do this, call the Federation at (817) 868-4041 or go to their website at: www.fsmb.org and click on

"Transcript Requests". (The EBAHR also provides USMLE, FLEX, and SPEX examination scores.)

EXAMINATION

SCORES

Applicants who passed the NBME examination:

ARRANGE to have the NBME examination scores sent directly to the HMB. To do this, call the NBME Examinee

Records office at (215) 590-9500 or go to their website at: www.nbme.org/.

Applicants who passed the USMLE, FLEX, or SPEX examination:

ARRANGE to have the Federation send an 'Examination and Board Action History Report" (EBAHR) directly to the

HMB. To do this, call the Federation at (817) 868-4041 or go to their website at: www.fsmb.org and click on

"Transcript Requests". (The EBAHR also provides a board action history report.)

ARRANGE to have the Medical Council of Canada (MCC) send the scores or marks of the MCCQE or MCCEE directly

to the HMB. To do this, call the MCC at (613) 521-6012 or go to their website at: www.mcc.ca.

Applicants who passed the MCCQE or MCCEE:

Applicants who passed a state-produced examination:

ARRANGE to have the state (where you took the examination) send the scores directly to the HMB. (In addition,

proof of satisfactory completion of the SPEX examination must be sent to the Board.)

TO APPLY FOR

EXAMINATION

TO APPLY FOR THE USMLE OR SPEX call the Federation at (817) 868-4041 or go to their website at: www.fsmb.org.

USMLE applicants click on "USMLE". SPEX applicants click on "Post-licensure Assessment", then "Special Purpose

Examination" (SPEX).

U.S. CITIZEN, U.S.

NATIONAL, OR AN

ALIEN AUTHORIZED

TO WORK IN THE

U.S.

Pursuant to section 436B-10, Hawaii Revised Statutes, and federal law, all applicants are required to be a U.S. citizen,

U.S. national, or an alien authorized to work in the United States. This means that even if an applicant meets the

education, training and examination requirements for licensure, that applicant will not be issued a license if that

applicant is not a U.S. citizen, U.S. national or an alien authorized to work in the United States.

However, the Board may issue the applicant a conditional approval that signifies that the applicant has met the

education, experience and examination requirements for licensure. This conditional approval is not a license to

engage in the profession and does not authorize the applicant to work in Hawaii.

To obtain authorization to work in the United States, the applicant may contact the U.S. Citizenship and Immigration

Services ("USCIS") at: http://uscis.gov or 1-800-375-5283.

Once the applicant submits evidence to the Board that the USCIS has authorized the applicant to work in the U.S.

(without conditions or other encumbrances), provides a Social Security Number and has met all of the licensing

requirements, the applicant may be issued a license, provided that there is no change in the applicant's status or

the information that was originally submitted. The Board may ask the applicant to submit up-to-date documents

to determine whether there have been any changes and whether the applicant still qualifies for licensure.

The conditional approval is valid for two (2) years. An applicant must obtain the appropriate USCIS authorization

within this two (2) year period in order to have a license issued. If the applicant is unable to meet this deadline, the

applicant may be required to reapply for licensure and meet all of the requirements in effect at the time.

(CONTINUED ON PAGE 8)

-7-

CERTIFICATION

OF APPLICANT

Please read the certification at the end of the application and sign and date it.

RELEASE OF

INFORMATION

If an agency or individual is assisting you with the licensure process, we will not be able to release any information to

them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of

Information to Third Party, sign and date it.

MAILING ADDRESS APPLICATION AND ITEMS are to be:

Mailed to:

Hawaii Medical Board

DCCA, PVL Licensing Branch

P.O. Box 3469

Honolulu, HI 96801

Delivered to:

Hawaii Medical Board

DCCA, PVL Licensing Branch

335 Merchant Street, Room 301

Honolulu, HI 96813

Phone: (808) 586-3000

COMPLETE

APPLICATION

We are unable to take action on an application unless it is complete. Therefore, please ensure that we have

received all the documents necessary.

To do this, you may call (808) 586-3000 to inquire about the status of your application. If an agency is assisting with

your application, we will release this information to them when you provide us with written authorization. (See

Release of Information).

ABANDONMENT

OF APPLICATION

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to

provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to

provide evidence of continued efforts includes, but is not limited to: (1) failure to submit any required information

and documents requested by the licensing authority within two consecutive years from the last date the documents

and information were requested, or (2) failure to complete any additional requirements for licensure that remain

after approval of your application, such as attempting to complete an exam requirement, within two consecutive

years from the date your application was approved, or (3) failure to provide the licensing authority with any written

communication during two consecutive years indicating that you are attempting to complete the licensing process.

If an application is deemed abandoned, the applicant shall be required to reapply for licensure and comply with the

licensing requirements in effect at the time of the reapplication.

LICENSE

RENEWAL

MD LICENSES expire on January 31 of each even-numbered year.

MDG LICENSES expire on January 31 each year.

About 2 months before the license expiration date, a renewal application is mailed to all licensees at their address

of record. If you do not receive a renewal application approximately one month prior to the license expiration date,

contact the Licensing Branch at (808) 586-300 for assistance. To ensure that you receive a renewal application, keep

the Board informed of your address. Licenses that are not renewed by the deadline are forfeited and the holders of

a forfeited license are considered unlicensed and may not practice. After two years license forfeiture, reapplication

is required.

-8-

LAWS AND

RULES

The pertinent laws and rules are posted on our website free of charge at: cca.hawaii.gov/pvl. Click on "Medical

and Osteopathy".

Alternatively, you may obtain copies by sending a written request to: Licensing Branch, PVL, P.O. Box 3469,

Honolulu, HI 96801.

1. Chapter 453, Hawaii Revised Statutes

2. Chapter 85, Hawaii Administrative Rules

3. Chapter 436B, Hawaii Revised Statutes

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit

your request.

Print Form

Application for License -

PHYSICIAN (MD License) or

PHYSICIAN employed by Hawaii

State or County Government

(MDG License)

Access this form via website at:

cca.hawaii.gov/pvl

Read Requirements and Instructions before completing this application.

Check type of license applying for: MD MDG

FOR BOARD USE ONLY

Approved

Denied

Initials/Date: Effective Date:

License No.

MD - MDG -

License No.

Legal Name (First, Middle) (Last)

Residence Address (include apt. no., city, state and zip code)

Mailing Address (ONLY if different from above)

Social Security Number Phone No. (days)

Other Names Used

Birth date

Check Exam Taken:

NBME

MCCQE

COMBINATION OF NBME, FLEX & USMLE

FLEX USMLE

STATE-PRODUCED & SPEX

Check answers:

Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the U.S.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Are you a graduate of a U.S. or Canadian medical school? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Are you a graduate of a Foreign medical school (FMG)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Check answers and provide details as directed for any "YES" response to the questions below:

Have you ever held a license in Hawaii? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

If response is "YES", specify type of license and dates below:

Has it ever been revoked, suspended, placed on probation, surrendered, reprimanded, admonished, or otherwise

subject to disciplinary action; or have you ever been issued a letter of concern; or have you ever entered into a

consent order or settlement agreement?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

Is any disciplinary action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Are you presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Have you ever been denied a license or withdrawn an application for licensure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

If response is "YES", attach a detailed explanation on a separate sheet, which includes state or country where action

is pending or took place, relevant dates, action taken and reasons for such action. Arrange to have certified

documents from each state in which disciplinary action was taken or is pending or being investigated sent directly

to the Board. (Include Findings of Fact, Conclusion of Law, Recommended Order, Final Order and whether you have

been reinstated. If reinstated, date and conditions of license.)

MD-01 1016R

(CONTINUED ON PAGE 2)

CRF . . . . . . . . . . . . . . . . 324 . . . . . . . . . . . . . . . . $74/$148

1/2 Ren . . . . . . . . . . . . 300 . . . . . . . . . . . . . . . . $97

Service Charge . . . . . BCF . . . . . . . . . . . . . . . . $25

MD: Appl/Lic . . . . . . . . . . . . 323/312 . . . . . . . . . . . . $50/$97

MDG: Appl/Lic . . . . . . . . . . . . 323/312 . . . . . . . . . . . . $25/$65

With regard to any medical license to practice in any state or country:

PERSONAL E-Mail Address

Have you ever been subject to adverse or disciplinary actions (e.g. any remediation, restriction, removal from

patient care, probation, suspension, termination, extra training requirement, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

Is any disciplinary or adverse action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Are you presently being investigated? . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Have you ever withdrawn or resigned (voluntary or otherwise)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Have you ever been issued a notice of contract termination, non-renewal or non-promotion? . . . . . . . . . . . . . . . . . . . . YES NO

Have you ever been subject to disciplinary or adverse actions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Is any disciplinary or adverse action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Print Name of Physician: Date:

-2-

(CONTINUED ON PAGE 3)

YES NO

With regard to any medical training program or facility, including, but not limited to medical school, residency, or

fellowship training programs:

With regard to any state, federal, or local controlled substance agency:8.

Are you presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been denied or withdrawn an application? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been issued a notice of non-renewal or termination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

9. With regard to any federal or military professional or disciplinary body:

Have you ever been subject to disciplinary or adverse actions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Is any disciplinary or adverse action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Are you presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been denied or withdrawn an application? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been issued a notice of non-renewal or termination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

10. With regard to any hospital privileging or credentialing body, grievance committee or any other medical group:

Have you ever been subject to disciplinary or adverse actions (e.g. any remediation, proctorship, restriction,

removal from patient care, probation, suspension, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Is any disciplinary or adverse action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Are you presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been denied or withdrawn an application for privileges or membership, or have you ever

resigned, surrendered, been terminated or failed to renew your privileges or membership? . . . . . . . . . . . . . . . . . . . . . .

Have you ever been issued a notice of non-renewal or termination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction or

organizations involved, relevant dates, action taken, and reason for such action.

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction or

organizations involved, relevant dates, action taken, and reason for such action.

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction or

organizations involved, relevant dates, action taken, and reason for such action.

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction or

organizations involved, relevant dates, action taken, and reason for such action.

With regard to any medical societies or specialty boards:11.

Have you ever been subject to disciplinary or adverse actions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Is any disciplinary or adverse action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

Print Name of Physician: Date:

-3-

(CONTINUED ON PAGE 4)

Are you presently being investigated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

Have you ever been denied or withdrawn an application for membership, or have you ever resigned,

surrendered, been terminated or failed to renew your membership? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been issued a notice of non-renewal or termination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction or

organizations involved, relevant dates, action taken, and reason for such action.

With regard to professional liability:12.

a) Have any claims of malpractice ever been filed against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

b) Has any insurance carrier ever denied, conditioned, curtailed, limited, suspended, or revoked your coverage? . . . . YES NO

If response is "YES", attach a detailed explanation on a separate sheet, which:

•

includes the date of the case (month/year), jurisdiction (State, etc.) nature of the case, allegations, and

amount paid on your behalf. Information is to be provided on all settlements, judgments, awards, and

claims (including those for which no money was paid); and/or

provides the name and address of your insurance carrier, specific circumstances, date and action taken.

•

13. With regard to participation in any health plan or Federal or State health care program:

Have you ever relinquished participation or certification, or been denied, terminated, sanctioned, penalized,

decertified or otherwise excluded from participation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever been convicted of insurance fraud? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .b)

If response is "YES", attach a detailed explanation on a separate sheet, which includes the bodies of jurisdiction

relevant dates, allegations, charges, disposition, action taken and reasons for such action.

YES NO

14.

In the past five years, have you been addicted to, dependent on, or a habitual user of alcohol or of a narcotic,

barbiturate, amphetamine, hallucinogen, or other drug having similar effects? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If response is "YES", attach a detailed explanation on a separate sheet.

YES NO

15. Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . . . . .

Explain "YES" response on a separate sheet with detailed information and attach certified court documentation

on the date, place, violation of each conviction and fulfillment of conditions for each sentence.

YES NO

EDUCATION

Name of Medical School

INTERNSHIP, RESIDENCY &

FELLOWSHIP

Location

(City/State or Country)

Degree Earned

Dates (mo/yr)

From To

Name of Residency Program

Location

(City/State or Country)

Dates (mo/yr)

From To

Print Name of Physician: Date:

-4-

SYNOPSIS

Medical Practice (Attach additional sheets if necessary)

Dates (mo/yr)

From To

LICENSES

Name of Jurisdiction

(Attach additional sheets if necessary)

Date Issued

Expiration

Date

License Number

Date Verification

Requested

HOSPITAL

Name of Hospital

(If none, state "None")

Location

(City/State or Country)

Dates (mo/yr)

From To

Date Form

Requested

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

CERTIFICATION OF APPLICANT:

I certify that the statements, answers, and representations made in this application and in the documents attached are true and

correct. I understand that this certification and any misrepresentation are grounds for the denial, refusal or subsequent revocation of license

and is a misdemeanor (Section 710-1017, and Sections 436B-19, and 453-8, Hawaii Revised Statutes). I further certify that I have read and will

abide by the provisions of Chapter 453 and Chapter 85.

Signature of Applicant

Date

Release of Information to Third Party:

To assist me in the licensing process, I authorize the HMB and staff to release any and all information regarding my application (including,

but not limited to, application status, examination scores, disciplinary or criminal history, National Practitioner Data Bank Report, AMA Profile)

to the following third party:

Name of Individual who is assisting you:

Name of Organization:

Address of Organization:

Signature of Applicant

Phone Number:

Date

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NAME

Require Instruct App For Physician 11.18R (Hawaii)

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