Ebahr Form – Fill Out and Use This PDF

Request for EXAMINATION AND BOARD ACTION HISTORY REPORT (EBAHR)

The Federation of State Medical Boards’ Examination and Board Action History Report (EBAHR) will certify whether you have previously taken the examination(s) designated by you on the attached form. If you have scores on record, the EBAHR will certify a complete history of your scores for the designated examination(s). See the reverse side of this instruction sheet for available examination history. The EBAHR will also include an indication, if applicable, of any action taken against you and reported to the Federation by a licensing or disciplinary board and/or other credentialing agency. The Federation considers your examination scores to be confidential and, therefore, requires your authorization in order to provide an EBAHR to you or to a third party.

NOTE: Licensing authorities generally require that EBAHRs be forwarded directly from the Federation rather than being submitted by you with other documents.

GENERAL INSTRUCTIONS FOR REQUESTING AN EBAHR

Attached is an EBAHR request form. The EBAHR fee is $65. You may designate up to two (2) recipients for each $65 fee (e.g. # of EBAHRs/fee: 1-2/$65, 3-4/$130, 5-6/$195, etc.) as indicated in Section III, Part B of the EBAHR request form.

Once an EBAHR request has been submitted, only the recipient(s) listed on that EBAHR form will be processed, and the fee may not be applied to an additional recipient requested at a later date. The Federation issues official transcripts within five (5) business days of receiving of the completed EBAHR request and appropriate fee. Express shipping to addresses within the US and its territories is available for an additional fee of $25 per recipient. Most state medical boards receive official transcripts in electronic format via a secured website. (For a list of medical boards currently receiving an electronic transcript please go to www.fsmb.org/transcripts). For those boards that do not receive transcripts electronically, the $25 ensures express shipping of the transcript. Express service does not deliver to P.O. Box addresses. All other transcripts are sent via first class mail.

Checks or money orders should be made payable to the FSMB. A $25 fee will be charged on any returned checks, and no further services from the Federation will be made available until full payment is received.

NOTARIZING THE EBAHR REQUEST FORM

The EBAHR request form MUST be notarized in Section IV, Part C. Please use the following checklist to ensure proper notarization:

I.Notary’s Stamp/Seal

II.Notary’s Name III. Notary’s Signature

IV. Notary’s Commission Expiration Date

V.Date of Notarization (must be dated within the last six months)

The notary may attach an affidavit, or cover sheet, if he/she chooses. Some states require an affidavit to be used instead of notarizing the actual document. Affidavits must also meet the above checklist of requirements and be attached to the EBAHR request form. Photocopies of the notarization will NOT be accepted.

MAILING THE EBAHR REQUEST FORM

All EBAHR requests are processed as they are received. The Federation will not hold an EBAHR request pending the release of scores at a later date. If you have recently taken USMLE Steps 1,2, or 3 and need that score to appear on your EBAHR, do not send this request until you have received your official score report for that Step. Once the EBAHR request form is completed and properly notarized, mail it, along with the appropriate payment to one of the addresses below.

If you have any questions regarding EBAHR/Transcript requests, please contact Exam Services at (817) 868-4041.

RETAIN THIS PAGE FOR YOUR INFORMATION

EBAHR REQUEST INSTRUCTIONS, PAGE 1 OF 2

Request for EXAMINATION AND BOARD ACTION HISTORY REPORT (EBAHR)

SECTION I - Personal Information

PLEASE TYPE OR PRINT CLEARLY

Last Name/Surname

First and Middle Name

Alternate or Previous Name

Address

FIN

(Federation Identification Number, if known)

USMLE ID Number

(if applicable/known)

(City, State, Zip)

Phone

Date of Birth

Month

Day

Year

(Daytime Phone: area code and number)

E-mail _______________________________________________

National Identification Number (NID)

U.S. Social Security Number

(Not applicable if you provided a U.S. Social Security Number)

Country of Citizenship upon entering medical school

NID Country

Medical School Name, City & Country

Graduation Date (Mo/Year)

Sex: Male

Female

ECFMG Number

SECTION II - Calculation of Required Payment (The EBAHR fee is $65 payable to the Federation of State Medical Boards via check or money order.)

Number of Parties (listed in Section III, Part B) to which an EBAHR is to be sent. You may request up to two (2) EBAHRs for each $65 fee. 1-2/$65

3-4/$130 5-6/$195, etc. $ ________

(#EBAHRs/fee) Once an EBAHR request has been submitted, only the recipient(s) listed on that EBAHR form will be processed, and the fee may

not be applied to an additional recipient requested at a later date.

Total Payment Required = $ ________

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Page 1 of 2

PLEASE TYPE OR PRINT CLEARLY

B.WHERE DO YOU WANT YOUR EBAHR/TRANSCRIPT TO BE SENT? Please provide complete name, address and phone number to which the EBAHR is to be sent.

(Check the Express box if you want the EBAHR to be sent via overnight carrier for an additional $25 per recipient in the US and it territories only).

Express		Express
Address		Address

Phone

Phone

Once an EBAHR request has been submitted, only the recipient(s) listed on this EBAHR form will be processed, and the fee may not be applied to an additional recipient requested at a later date. (If EBAHRs are to be sent to additional recipients, please attach a separate sheet clearly listing names and addresses.)

C.Provide signature to authorize the release of examination information indicated in part A of this section to the parties listed in part B of this section and to authorize a report of board action, if applicable.

I hereby authorize and request that the Federation of State Medical Boards of the United States, Inc., provide an Examination and Board Action History Report as described herein. I understand and acknowledge that, in addition to my examination scores, the EBAHR will indicate any action taken against me and reported to the Federation’s Board Action Data Bank by a US/Canadian licensing and/or disciplinary authority or other credentialing agency. Further, I hereby waive all rights or claims against the Federation for its provision of the examination history and other information hereby requested.

D.Each EBAHR notarization requires the following: Notary’s Stamp/Seal; Notary’s Name; Notary’s Signature; Notary’s Commission Expiration Date; Date of Notarization (MUST BE WITHIN THE LAST SIX (6)

MONTHS)

The notary may attach an affidavit, or cover sheet, if he/she chooses. Some states require an affidavit to be used instead of notarizing the actual document. Affidavits must also meet the above requirements and be attached to the EBAHR request form. Photocopies of the notarization will NOT be accepted.

Failure to provide sufficient and accurate information and/or failure to sign and properly notarize the authorization may significantly delay your request. Do not send license application or other documentation to this office.

10/2010