Ebahr Form PDF Details

In an era of meticulous documentation and verification, the Federation of State Medical Boards’ Examination and Board Action History Report (EBAHR) offers a critical resource for individuals in the medical profession seeking to navigate the complex terrain of licensure and credentialing. Designed to provide a comprehensive account of an individual's examination history and any board actions taken against them, the EBAHR serves as a beacon of transparency and integrity in the healthcare field. It requires applicants to disclose their examination scores, which are regarded as confidential and necessitate the applicant's authorization for release. Furthermore, the process mandates that the EBAHR be sent directly from the Federation to designated recipients, emphasizing the importance of official documentation in maintaining professional standards. With a detailed instruction sheet and a notarization requirement to ensure authenticity, the EBAHR request process is meticulously structured to uphold the highest levels of accuracy and reliability. Operational logistics, such as processing fees, express shipping options within the US and its territories, and the stipulation against applicant submission, underscore the Federation's commitment to efficient and secure information dissemination. Additionally, the availability of scores for exams like FLEX, SPEX, and USMLE Steps 1, 2, and 3—while excluding others—reflects a focused effort to provide relevant data critical to medical licensing and practice in the United States and Canada.

QuestionAnswer
Form NameEbahr Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesak ebahr board, NBME, EBAHRs, fsmb

Form Preview Example

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.

Via First Class U.S. Postal Service ONLY

Without tracking or signature required services:

Federation of State Medical Boards

c/o Wholesale Lockbox

P.O. Box 970599

Dallas, TX 75397-0599

Via express tracking services for

FedEx, Airborne, UPS or U.S. Postal Service ONLY:

Attn: Exam Dept/EBAHR Form

Federation of State Medical Boards

400 Fuller Wiser Road, Suite 300

Euless, TX 76039-3856

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

AVAILABLE EXAMINATION SCORES

The Federation maintains scores for the following examinations:

FLEX — Federation Licensing Examination

SPEX — Special Purpose Examination

USMLE Steps 1, 2 and 3 — United States Medical Licensing Examination

The Federation DOES NOT maintain or have access to National Board of Medical Examiners (NBME) Parts I, II or III, or the Educational Commission for Foreign Medical Graduates (ECFMG), Foreign Medical Graduates Examination in the Medical Sciences (FMGEMS) Day 1 or Day 2. To obtain scores for these examinations, please contact the entity, which administered the examination to you.

For information concerning NBME Parts I, II and III administered by the NBME:

National Board of Medical Examiners 3750 Market Street

Philadelphia, PA 19104-3190 (215) 590-9500

For information concerning NBME Parts I, II and III administered by ECFMG or for information concerning FMGEMS:

Educational Commission for Foreign Medical Graduates 3624 Market Street

Philadelphia, PA 19104 (215) 386-5900

RETAIN THIS PAGE FOR YOUR INFORMATION

EBAHR REQUEST INSTRUCTIONS, PAGE 2 OF 2

10/2010

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(Federation Identification Number, if known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USMLE ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if applicable/known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City, State, Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of EBAHRs to be sent Express ($25 per recipient in the US and its territories only).

X

$25 = $ ________

Total Payment Required = $ ________

SECTION III - Authorization

A.Choose one or more of the following examination types to be included on your EBAHR. (FSMB cannot provide NBME or FMGEMS scores.)

FLEX

USMLE

SPEX

10/2010

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).

Attention

Attention

Express

 

Express

Address

 

Address

 

 

 

 

 

 

City

State

Zip

City

State

Zip

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.

Signature

Notary

Stamp or

Notary Seal

Here

Date

Certification of Identification (Certification by a Notary Public is Required.)

Name of Notary Public (please print) ________________________________________________________________________________________

I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this individual by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the individual, and (b) comparing the individual’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 individual on this _____________day of _______________ in the year of __________ .

State of ______________________________ County/Parish of __________________________________________.

Notary Public Signature ___________________________________________________ Commission Expiration Date__________________

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