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WEST VIRGINIA BOARD OF OSTEOPATHIC MEDICINE
405 Capitol Street, Suite 402
Charleston, WV 25301
(304) 558-6095 / Fax (304) 558-6096
www.wvbdosteo.org
APPLICATION FOR LICENSURE
INSTRUCTIONS
West Virginia Board of Osteopathic Medicine UA Instructions Packet
January 2017 Page 1 of 4
D.O. Application Process
The Federation of State Medical Boards
The Federation of State Medical Boards (FSMB) is a national non-profit organization representing the 70 medical and
osteopathic boards of the United States and its territories, serving as the national resource and voice on behalf of these
boards in their protection of the public.
Two services provided by FSMB that are often used by physicians when applying for licensure are the Federation
Credentials Verification Service (FCVS) and the Uniform Application for Physician State Licensure (UA).
Please be aware that FCVS and the UA are two different services. The FCVS application is only used to establish a
profile of credentials verified by primary sources. FCVS is not a licensure application. The UA is used as a licensure
application most commonly by physicians applying to multiple state boards. Both services may be used when applying to
a board for licensure. Check the board’s instructions to determine if FCVS is required or accepted but not required.
Using the UA to Apply for Licensure
The Uniform Application is used to apply for licensure only, not for credentials verification. Once the UA has been
completed and the one-time service charge has been paid, it can be updated and sent to other boards as needed.
Additional information required by a board, but not covered in the core UA, is gathered by completing a state board
specific UA addendum, various board or UA forms, and/or a board’s online addendum or separate online application.
Applicants using the UA must account for all time since medical school graduation, including non-working time as well as
postgraduate training and employment. Information on malpractice claims is also required. Having this information on
hand before starting the UA is highly recommended.
To begin or update your UA, visit
https://portal.fsmb.org/MyFsmb/ and click on the UA graphic, then sign in. You may also
visit
http://www.fsmb.org/ and click on Uniform Application in the Licensure menu to access the portal page.
Completing the UA
When completing your UA online, please complete all pages of the UA as instructed, noting the following:
• Refer to the state board to determine if entering your social security number is required.
• If not pre-filled, provide your home address and a separate address for business or postgraduate training. Both
Board Contact and Public Access selections must be made but you can use the same address for each selection.
All home addresses must be domestic, as fingerprint cards and other background information are mailed there.
• Enter each ACGME and/or AOA accredited training on the Accredited Training page. Enter all other training
programs in the United States and Canada on the Other Training page.
• You are not able to add or edit MD or DO license information in the UA because that information is sent directly
from the state boards into the FSMB system. If changes are needed, email
ua@fsmb.org with the correct
information. Depending on volume of license update requests, it may take 1-3 business days for the changes to
appear in your UA. Do not enter MD or DO license information under “Other”.
• Your Chronology of Activities should cover each of your activities (non-working time included) from medical
school graduation to present. Previously listed medical school and postgraduate training programs will pre-fill the
Chronology. Do not leave gaps. For each entry, use the first day of the month for start and end dates unless you
know the exact date. If you have military or locum tenens assignments, list each location separately.
• Clinical time indicates time spent seeing patients and practicing medicine. Administrative time indicates time
spent on paperwork, research, or teaching.
• Leave the signed malpractice liability claims section blank only if you have had no claims. List all pending claims.
West Virginia Board of Osteopathic Medicine UA Instructions Packet
January 2017 Page 2 of 4
• Upon accepting the Terms and Agreement and submitting the UA, first time UA users will be taken to a payment
page for the one-time service charge. This charge sustains the UA program and is separate from FCVS and state
board licensing fees.
• For a copy of your receipt, click on the “Home” link to return to the portal page, which will now have a Payment
link to all FSMB receipts in the upper right corner.
• To open your UA for editing and resubmitting to a board, or for submitting to a new board, sign in and choose the
appropriate board in the State Board section. Reselect the US Citizen query on the Identification page (it resets
each time a UA is submitted), make changes as needed, then submit or resubmit your UA.
• Refer to the UA FAQ at
https://www.fsmb.org/licensure/uniform-application/faq for answers to the most common
UA questions. If your issue isn’t listed, contact UA customer service at 800-793-7939 or email
ua@fsmb.org with
your username and a description of your issue. Provide a screenshot for each error you see.
In addition to completing the core UA online, applicants must:
• Unless otherwise noted in the board’s instructions, submit a notarized UA Affidavit and Authorization for Release
of Information form to the Board. The UA Affidavit is separate from the FCVS Affidavit and must be sent to the
Board, not to FCVS or FSMB. Follow the instructions on the form.
• Unless otherwise noted in the board’s instructions, have each full, temporary, training, or limited healthcare or
profession license or certification you have ever held in the United States or Canada verified by the granting
board, whether the license is currently active or inactive. To determine the fees and preferred verification method
for each board, use the resource at
http://www.fsmb.org/licensure/uniform-application/. If a board uses VeriDoc or
other electronic format for verifications, do not use the UA verification form.
• Complete the FCVS initial or subsequent application if applicable.
• Complete all other board requirements as instructed.
Using FCVS for Credentials Verification
After a physician completes an initial FCVS application to establish a profile of verified credentials (documents related
to identity, medical education, postgraduate training, etc.), FCVS staff contacts the primary source of each credential
for verification. Each verified credential is added to a personalized profile created for the physician. Completed
verifications are sent to each board designated to receive the profile during the application process.
After a physician completes a subsequent FCVS application, all new credentials are verified through primary sources.
An updated profile is then sent to each board designated during the subsequent application process.
Each medical and osteopathic board in the United States and its territories (except for Puerto Rico) accepts or
requires FCVS. Check the board’s instructions to determine if FCVS is required or accepted but not required.
To begin an initial or subsequent application for creating or updating your profile, visit
https://portal.fsmb.org/MyFsmb/
and click on the FCVS graphic, then sign in. You may also visit
http://www.fsmb.org/ and click on FCVS in the
Licensure menu to access the portal page. Please note: Designations to Self are for receiving your own copy of the
profile. Boards do not accept Self designations.
For assistance, use the messaging tool in FCVS or call 888-275-3287 with your FCVS ID or nine-digit Federation ID
(FID) between 8am and 5pm Central Time Monday through Friday.
West Virginia Board of Osteopathic Medicine UA Instructions Packet
January 2017 Page 3 of 4
BOARD APPLICATION CHECKLIST
NOT using
FCVS to
verify
credentials
Using FCVS
to verify
credentials
Completed online application (UA) and State Addendum
Completed State Addendum sent to Board.
Submit application fees as follows:
1. $400.00 to the Board
2. 2.25% processing fee to the Credit Card company
3. $125.00 Assessment Fee required by Senate Bill 602 passed by the 2016
Legislative Session
Submit an extra, recent (within 60 days) passport quality color photograph
As of January 1, 2017, all applicants must complete a Criminal Background Check.
Completed “Affidavit and Authorization for Release of Information” form submitted to
the Board.
Use VeriDoc (www.veridoc.org) to process license verifications. If a board does not
use VeriDoc, use the License Verification Form provided in this packet.
• fill in the top portion with the pertinent information
• copy and forward it to all states in which you are or have been licensed for
them to complete and return to our office
Mail a signed Malpractice Liability Claims form(s) after completing malpractice
section in the online UA.
Mail supporting documentation of name change (e.g. marriage certificate or divorce
papers) to the Board.
• Note: If your name has changed, and any of your licensure documentation
(internship certificate, medical school diploma, other licensure certificates,
etc.) shows a different name, you will need to provide documentation of this
change (e.g. marriage certificate or divorce papers).
Completed
via FCVS
Medical Education Verification form (Form #2) sent to the Board by all medical
schools attended. Download a
Medical School Verification form
• fill in the top portion with the pertinent information
• copy and forward it to each medical school you have attended for them to
complete and return to our office
Completed
via FCVS
A copy of your postgraduate training certificate(s) submitted to the Board.
Completed
via FCVS
(checklist continued on next page)
West Virginia Board of Osteopathic Medicine UA Instructions Packet
January 2017 Page 4 of 4
Postgraduate Training Verification Form sent to the Board from all programs you
attended. Download a
Postgraduate Education Verification
form
x fill in the top portion with the pertinent information
x copy and forward it to each hospital where you participated in any
postgraduate training program for them to complete and return to our office
x provide documentation of completion of the first year of postdoctoral
training (copy of intern certificate or letter from Director of Medical
Education of program)
x one year of clinical training must be in a program approved by the
American Osteopathic Association, which may also include a program
approved under the Association's Resolution 42 procedure; OR
x postgraduate clinical training in a program approved by the ACGME and 40
hours of CME in osteopathic medicine with osteopathic manipulative
treatment in courses approved, and classified as category 1A by the AOA
(with at least 25% of those hours on hands-on osteopathic manipulation)
Completed via
FCVS
Examination Transcripts sent to the Board.
Completed via
FCVS
Upon the completion of the application file, the applicant will be notified to schedule a face to face interview with one of
our Board Members. Our Board Members are located throughout West Virginia in Charleston, Vienna, Barboursville and
Pine Grove for the applicant's convenience.
West Virginia Board of Osteopathic Medicine UA Addendum
January 2017 Page 1 of 2
ADDENDUM TO APPLICATION
Applicant Name ________________________________________________________ Date _____________________
Please answer the following questions. If you answer “yes” to any of these questions, you are required to provide
full details on the reverse side of this sheet, or attach an additional 8 ½” x 11” sheet(s) if necessary.
1.
Have you ever been dropped, suspended, placed on probation, required remediation,
expelled, or requested to resign from any school, college, or university?
Yes No
2.
Have you ever been subject to an investigation of any kind by any licensing Board,
jurisdiction, or Agency?
Yes No
3.
Have you ever been licensed in this state and/or any other state or nation as a physical
therapist, nurse, physician’s assistant, or in any related capacity?
Yes No
4.
Have any of the licenses mentioned above or your license to practice Osteopathic Medicine
ever been suspended, revoked, or restricted in any way in any licensing jurisdiction?
Yes No
5.
Have you ever been denied Osteopathic Licensure in any licensing jurisdiction or been
granted a license under restrictions of any kind?
Yes No
6.
Have you ever discontinued practice for any reason for a period of one month or longer?
Yes No
7.
Have any proceedings ever been filed or instituted against you – either malpractice,
criminal, civil, or professional Board related?
Yes No
8.
Have you ever been convicted of a violation of or pled No Contest to any Federal, State or
local statute, regulation or ordinance, or entered into any plea bargain related to a felony or
misdemeanor?
Yes No
9.
Have charges, now or ever, been brought against you by any branch of the Armed Services
of the United States?
Yes No
10.
Have you ever been adjudged incompetent?
Yes No
11.
Have you ever received any form of psychotherapy or any other treatment for any mental
disorder, disability or illness of any kind?
Yes No
12.
If the answer to #11 is Yes, have you been released from such care in the present time?
When were you released? _____________ (Example mm/dd/yyyy)
Yes No
13.
Do you have any chronic medical illness or medical condition which would affect your ability
to practice your profession?
Yes No
14.
Have you ever been admitted to or confined within a hospital or institution for the purpose of
obtaining treatment or therapy for any mental or nervous disorder, disability or illness of any
kind?
Yes No
Have you ever had staff privileges denied, restricted or suspended, or have you ever
voluntarily resigned in lieu of disciplinary action or while under investigation?
Yes No
(continued on next page)
West Virginia Board of Osteopathic Medicine UA Addendum
January 2017 Page 2 of 2
Applicant Name ________________________________________________________ Date _____________________
Are you now or have you ever been enrolled in or participated in any drug, alcohol, or
impaired practitioners program?
Currently, the Board has only designated West Virginia Professionals Health Program, Inc.
for this service. If you have received any evaluation or treatment through a different service
or provider, you must answer “Yes” and provide a report of your treatment and progress
with your application.
Yes No
Have you ever been denied or relinquished privileges in any third party reimbursement
program whether governmental or private, including Medicaid and Medicare; or had such
participation limited, restricted, suspended, or revoked; or been warned, reprimanded,
requested to appear before, or fined by the responsible body?
Yes No
Are you a member of a state association?
Yes No
Are you a member of AOA?
AOA#:______________________________
Yes No
Primary Specialty___________________________________
Are you currently Board certified?
Yes No
Secondary Specialty_________________________________
Are you currently Board certified?
Yes No
Are you Active Duty Military?
Yes No
If you plan on practicing in West Virginia, where do you plan to practice?
_________________________________________________________________________
Pursuant to West Virginia Code §48A-5A-
5(c) each licensee must answer the
following questions and certify, under penalty of false swearing, that these answers
are true and correct.
Yes No
Do you have a child support obligation?
Yes No
If the answer to question 1, above, is yes, are you in arrearage?
Yes No
If the answer to question 2, above, is yes, does your arrearage equal or exceed the amount
of child support payable for six months?
Yes No
Are you the subject of a child support related subpoena or warrant?
Yes No
____________________________________ ___________________________ ___________________
Applicant's Signature Applicant's Printed Last Name Date of Signature
LICENSE VERIFICATION FORM
Send a copy to the Licensing Board in every state in which you are or ever have been licensed
– active and inactive. (also include Educational or Training Licenses.)
Note: Licensing Boards in some states charge a fee for this. Contact their office before
mailing this form to them.
I have applied for a license to practice Osteopathic Medicine and Surgery in the state of West Virginia.
Before my request for a license can be reviewed, a background investigation must be completed. I hereby
authorize you to release the following information to the West Virginia Board of Osteopathy.
________________________________ _______________________________
Name in Full (Please Print) (Signature of Applicant)
_______________________________ ________________________________________
License # Issue Date
______________________________________________________________________________________
Current Address
___________________________________________ ______________________________________
Birthdate Soc. Sec. # Other Names Used for Licensure
This section to be completed by State Licensing Board where you are or were licensed:
State of:________________________________________________________
Full Name of Licensee:___________________________________________
Graduate of:_____________________________________________________
License #:________Issue Date:__________ Expiration Date:__________
Current Status:__________________________________________________
License Method: ( ) State Board Exam ( ) National Board
( ) Endorsement/Reciprocity ( ) FLEX
( ) Other:___________________________________
Has the applicant ever been warned, censured or in any other manner disciplined
or has applicant’s license been revoked, suspended, surrendered or in any other
manner limited by a licensing or disciplinary authority in your state? YES___ NO___
If yes, please explain,____________________________________________________
Is the applicant currently the subject of a pending investigation by a licensing or
disciplinary authority in your state that is likely to result in formal disciplinary action? YES___ NO___
Cannot answer under state law ___
If yes, please explain _____________________________________________________
Comments:___________________________________________________________________
Signed:_________________________
(Board Seal) Title:__________________________
Date:___________________________
LICENSING BOARDS: PLEASE RETURN THIS PAGE DIRECTLY TO:
***** WEST VIRGINIA BOARD OF OSTEOPATHIC MEDICINE *****
405 Capitol Street – Suite 402
Charleston, WV 25301
MEDICAL EDUCATION
(Page 1 of 2)
(Copy this form for multiple schools)
In applying for a license to practice medicine and surgery, the West Virginia Board of Osteopathy requires this form to be
completed by each medical school I attended.
Name: _______________________________________________________________________________
Name if different when diploma awarded: ______________________________________________
Social Security: _________________________________ DOB: _______________________
The applicant’s social security number is to be used for purposes of identification and may not be used for any other reason.
Waiver for release of information: I authorize the Medical School below to provide any and all information pertaining to my
medical education at your institution to the WV Board of Osteopathy.
______________________________________ ________________
Applicant’s Signature Date
Certificate of Dean, Secretary, or Registrar of Medical College
(Must be completed by a representative of the Medical School)
This is to certify that_________________________________________
(Name of Graduate)
has satisfactorily completed__________ years of medical education
at the__________________________________________________________
(Name of Medical College)
located at______________________________________________________.
(Address of Medical College)
The aforesaid graduate received the degree of___________________
from this College on____________________________________________.
(month, day, year)
____________________________
(Signature)
SEAL OF COLLEGE ____________________________
(Title)
Return this form to:
West Virginia Board of Osteopathic Medicine
405 Capitol Street – Suite 402
Charleston, WV 25301
Medical School Verification – Page 2 of 2
(Copy this form for multiple schools)
APPLICANT’S NAME:________________________________________
VERIFICATION OF MEDICAL EDUCATION (continued)
Unusual Circumstances: The following questions apply to unusual circumstances that occurred during any part of the
individual’s medical education. Please check the appropriate response 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).
1. Do the records reflect (an) interruption(s) or extension(s) in his/her medical education? YES NO
If YES, please select the reason(s) for, indicate the dates of the interruption(s) or extensions(s) and check
whether the interruption/extension s approved or unapproved.
From Mo/Yr To Mo/Yr 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)
Participation in non-degree research
Other (Please specify):
2. Do the records reflect that this individual 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 additional documentation to this report.
From Mo/Yr To Mo/Yr
Academic Probation
Probation for unprofessional conduct/behavior
Probation for other reason
Please specify reason:
3. Do the records reflect that this individual was ever disciplined for unprofessional conduct/behavioral reasons by the medical
school or parent university? YES NO
If YES, please provide detailed documentation/information about the circumstances and
Outcome(s).________________________________________________________
__________________________________________________________________
4. Do the records reflect that this individual was ever the subject of negative reports or an investigation by the medical school
or parent university? YES NO
If YES, please provide detailed documentation/information about the circumstances and
outcome(s) .________________________________________________________
__________.________________________________________________________
5. Do the records reflect that there were 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 provide detailed documentation/information about the nature of the limitations or special
requirements._______________________
Uniform Application for Physician State Licensure Applicant _________________ _________________
September 2016 UA Postgraduate Training Verification Form
Postgraduate Training Verification Form (Form #3)
Applicant: DO NOT COMPLETE THIS FORM IF YOU ARE USING FCVS. FCVS verifies this data for you.
If you are not using FCVS, complete Section 1 below. Send this form to the current program director of your
postgraduate training program. Copy this form for multiple programs.
Program Director or Designated Official: Complete Section 2 of this form. Report internship, residency,
and fellowship years on separate pages. Make copies of this form and attach additional pages as needed.
Mail completed pages and any other documentation if needed to the board at the address listed in Section 1.
Section 1: Applicant Information
First name ______________________ Last name ______________________ Practitioner Type MD DO ____
Middle name ____________________ Suffix ________ SSN* ____________ Birth date (mm/dd/yyyy) ____________
Name if different when diploma awarded ________________________________________________________________
Name of postgraduate training program _________________________________________________________________
*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 request that the program director or a designated official complete Section 2 of this
form as outlined above. I authorize the postgraduate training program listed above to provide any and all information
pertaining to my training there to the board listed below:
Board name _________________________________________
Mailing address _________________________________________
City/State/Zip _________________________________________
Applicant signature ___________________________________________________________ Date _______________
Section 2: Postgraduate Training Verification
Institution name _____________________________________ Affiliated school ________________________________
Institution address w/country _________________________________________________________________________
Program year(s) _____ Attendance (mm/yyyy) from __________ to __________ Specialty ________________________
Program type Internship Residency Internship/Residency
Transitional Fellowship Fellowship/Research Other _____________________________
Training status Completed In Training Not Started Leave of Absence Withdrawn Dismissed
Accredited by ACGME AOA APPAP CFPC LCGME RCPSC RSC None
The following questions apply to unusual circumstances that occurred during any part of the individual’s training. Check
the appropriate responses and explain any “Yes” response on a separate sheet of paper. Attach pages as needed.
1.
Did this individual ever take a leave of absence or break from 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 because of questions of
academic incompetence, disciplinary problems, or any other reason?
Yes No
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 ___________________________ Date _______________
(If no seal is available, this form must be notarized.) Phone number _________________ Fax number ___________
Email ______________________________________________
Please mail this completed form and any other items to the board at the address listed in Section 1. Thank you.
For State Board Use Only
WV Board of Osteopathic Medicine
405 Capitol Street, Suite 402
Charleston, WV 25301
Uniform Application for Physician State Licensure Applicant _________________ _________________
September 2016 UA Affidavit and Authorization for Release of Information
Affidavit and Authorization for Release of Information
Applicant: In the presence of a notary public, sign this form with attached photo. If you are using FCVS for
credentials verification, consider having that form notarized at the same time. Send the separate notarized
FCVS form to FCVS. Do not send this form to FCVS as doing so will delay your licensure.
Send this form to the board you are applying to for licensure. For state medical and osteopathic boards,
refer to http://www.fsmb.org/policy/contacts for contact information. Include all other required materials.
To: Board name _________________________________________
Mailing address _________________________________________
City/State/Zip _________________________________________
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 __________________________________________ My Notary Commission Expires _________________
Applicant Photograph
Securely tape or glue a recent
(per the board’s instructions) 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, first name, middle initial, and suffix (e.g., Jr.)
_________________________________________________________________________________
Date of signature (must correspond to date of notarization)
[Please note: The Notary Public seal should overlap the bottom of the photo to the left.]
For State Board Use Only
WV Board of Osteopathic Medicine
405 Capitol Street, Suite 402
Charleston, WV 25301
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Completed 18 June 2021

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