Form 4 Md PDF Details

For many foreign medical school graduates looking to practice medicine in the United States, navigating through the licensure process can be both daunting and complex. Key to this journey is the FORM #4 (MD) from the Oklahoma State Board of Medical Licensure and Supervision, a critical document that verifies the completion of clinical clerkships in the United States, its territories, or possessions. This form becomes necessary when those clerkships are completed at institutions after July 1, 2003, and it ensures that these clerkships were conducted in hospitals and schools with programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Each clerkship requires a separate form, which must be directly mailed to the Board. It includes comprehensive details such as the student's name, social security number, date of birth, medical school, the facility where the clerkship was completed, the clinical area of the clerkship, and an attestation by the facility's program director or instructor regarding the accreditation and the validity of the information provided. The process underscores both the rigorous standards upheld by the medical community in Oklahoma and the steps foreign graduates must undertake to ensure their qualifications are recognized.

QuestionAnswer
Form NameForm 4 Md
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMD_Form_4 oklahoma verification of clinical clerkship form

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FORM #4 (MD)

Oklahoma State Board of Medical Licensure and Supervision

P.O. Box 18256, Oklahoma City, OK 73154-0256

VERIFICATION OF CLINICAL CLERKSHIP

In the event a foreign medical school utilized clerkships in the United States, its territories or possessions, and the applicant graduated from medical school after July 1, 2003, such clerkships shall have been performed in hospitals and schools that have programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).

One form must be completed and mailed directly to the Board for each clerkship.

This is to certify that__________________________________;

____ ____ ____ / ____ ____ / ____ ____ ____ ____,

Student’s Name

U.S. Social Security Number

____________________________ a student of _______________________________________________________________

Date of BirthMedical School

Completed a clerkship offered by __________________________________________________________________________

Name of Facility

_____________________________________________________________________________________________________

 

 

 

Address of Facility

 

 

From________________________________________

through _________________________________ in the clinical area

Month

Day

Year

Month

Day

Year

Of____________________________________________________.

Clinical Area

This facility has programs that are accredited by ACGME in the areas of ____________________________________________.

Specialty

I, ___________________________________________, swear or affirm that I am/was the individual facility program director or

instructor for the student named above during the clerkship indicated and that I have carefully read and completed this form and that the statements made herein are accurate.

 

___________________________________________________________

Institution

Type or Print Name of Facility Program Director or Instructor

 

Seal

 

 

 

 

___________________________________________________________

 

Address

 

 

 

___________________________________________________________

 

City

State

Zip Code

 

_____________________

________________________________

 

Telephone Number

Signature

 

In the absence of an official institution seal, the Facility Program Director or Instructor’s signature must be notarized.

Signed and sworn before me this ________ day of ____________________(Month) _____________(Year).

 

_____________________________________________________________

 

Notary Public Signature

Notary

 

Seal

My Commission Expires:_________________________________________

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