Texas L Licensure Details

This general guide will help you ascertain how much time it'll require you to complete form l for texas medical board, how many pages it has, and some other unique specifics of the PDF.

QuestionAnswer
Form NameForm L For Texas Medical Board
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameslicensure evaluation verification, texas form l, texas form physician, licensure evaluation verification get

Form Preview Example

FORM L

Physician Licensure Evaluation

Verification of Postgraduate Training and Professional Evaluation

Texas Medical Board

APPLICANT:

Complete the information in this box. You must have evaluations from every facility with which you have been affiliated in the past 5 years. Note – your licensure analyst may require additional evaluations outside the past 5 years.

Applicant’s Current Full Name: ____________________Name at time of affiliation if different: _______________________

Printed

Printed

Applicant’s Date of Birth: ______________

Applicant TMB ID# _________________

Applicant’s Address: ____________________________Telephone: ________________ E-Mail: ____________________

Name of Evaluating Hospital/Institution _________________________________________________________________

Address of Evaluating Hospital/Institution _______________________________________________________________

Dates of affiliation From (mm/yy) ___________ To (mm/yy) _________

Department of Affiliation_______________________

 

 

 

 

Your position at the time of affiliation:

Intern

Resident

Fellow

Faculty

Staff

I hereby authorize all hospitals, institutions or organizations, my references, personal physicians, employers (past, present and future), business or professional associates (past, present and future) and all governmental agencies (local, state, federal, or foreign) to release to the Texas Medical Board or its successors any information, files or records, including medical records, educational records, and records of psychiatric treatment and treatment for drug and/or alcohol abuse or dependency, requested by the Board in connection with this application, necessary to determine my medical competence, professional conduct, or physical and/or mental ability to safely engage in the practice of medicine. I further authorize the Texas Medical Board or its successors to release to the organizations, individuals, or groups listed above, any information, which is material to this application, or any subsequent licensure.

I authorize the release of the information contained in this evaluation form to the Texas Medical Board.

___________________________________________________

Applicant’s Signature

EVALUATING PHYSICIAN:

A physician who currently holds one of the following positions must complete this evaluation: Chief of Staff, Department Chairman, Medical Director, or Training Director. Letters of recommendation or standard institution verification forms will not be accepted in lieu of this form.

After completing this evaluation, place this form in an envelope of the hospital/institution that you represented, seal the envelope and place your signature over the outside sealed envelope flap.

If you have any questions regarding how to complete this form contact the Licensure Department at 512-305-7030.

 

 

 

 

 

 

Title:

Chief of Staff

 

 

 

 

 

 

 

Department Chairman

Evaluating Physician’s

 

 

 

 

Medical Director

Name/Degree:

 

 

 

 

 

Training Director

 

 

 

 

Printed

 

 

Title:

 

 

 

 

 

 

 

Phone:

 

Address:

 

 

 

Fax:

 

 

E-Mail:

 

 

 

Evaluating Physician's License Number and

 

 

 

 

 

 

State of Licensure

 

 

 

 

 

 

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 06.14

FORM L

Applicant's Name___________________________________________Page 2

Printed

This is important: All information on this Form L, (including attachments that you provide as the Evaluating Physician) regarding a licensure applicant is confidential pursuant to §164.007(c) of the Medical Practice Act. However, the Board must provide a copy of this Form L and attachments to an applicant when an application is referred to the Licensure Committee for licensure determination. Any information furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity from Civil Liability.

VERIFICATION OF POST GRADUATE TRAINING

 

This section relates to postgraduate training. If this individual did not complete postgraduate training at this institution please

 

 

skip to the Verification of Professional History section.

 

 

 

 

 

 

 

PROGRAM PARTICIPATION:

 

Department:

 

 

 

 

 

 

 

 

 

 

 

 

 

Report incomplete postgraduate years (PGY)

PGY: _______

___________________________________

 

 

 

separately from those that were successfully

 

 

 

___ Internship

 

 

 

 

 

 

completed.

 

From: ___/___/___

To: ___/___/___

 

 

 

___ Residency

 

 

 

 

 

 

 

 

 

 

If the postgraduate year is currently in progress,

___ Fellowship

Credit received?

 

 

 

 

___ Research

 

 

 

 

 

 

report the expected completion date in the “To” field.

Full

*Partial

in progress

 

 

 

 

 

 

 

Report Internships, Residencies and Fellowships

 

*For partial credit– how many months?______

 

 

separately. Use one section per department.

 

Department:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PGY: _______

___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

___ Internship

From: ___/___/___

To: ___/___/___

 

 

 

 

___ Residency

Credit received?

 

 

 

 

 

 

___ Fellowship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ Research

Full

*Partial

in progress

 

 

 

 

 

*For partial credit– how many months?______

 

 

 

 

 

 

 

 

 

UNUSUAL

1. Did this individual ever take a leave of absence or break from training?

Yes No

 

CIRCUMSTANCES:

2. Did this individual resign from training? Yes ฀ NO

 

 

 

 

Please attach an

3. Were any limitations or special requirements placed upon this individual for professionalism or

 

behavioral issues? Yes No

 

 

 

 

 

explanation for any

 

 

 

 

 

4. Did this individual ever receive a written warning or documented counseling about his/her

 

“yes” response.

 

behavior? Yes ฀ NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Was this individual ever placed on probation for any reason? Yes ฀ NO

6.Is this individual currently under investigation? Yes No

7.Were this individual’s privileges or duties ever reduced, suspended, or revoked? Yes No

8.Did this individual experience delayed promotion or delayed advancement to the next level? Yes No

9.Was this individual informed his/her contract would not be renewed? Yes No

10.Was this individual suspended, terminated, or dismissed from training? Yes No

VERIFICATION OF PROFESSIONAL HISTORY

1.

This evaluation is based on Personal Knowledge

Review of Credential File

 

2.

How long have you known the applicant? Years________ Months ________

 

3.

Is the applicant related to you?

 

Yes

No

4.

Do you know the applicant well?

 

Yes

No

5.

Has your acquaintance with the applicant continued until recent date?

Yes

No

6.Do you consider the applicant:

(a) Reliable?

Yes

No

(b) Ethical?

Yes

No

(c) Of good character?

Yes

No

7.Please rate the applicant:

Excellent

Good

Average

Poor

(a)Professional ability

(b)Attention to duties

(c)Breadth of education

(d)Interpersonal skills

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 06.14

FORM L

Applicant's Name___________________________________________

Page 3

Printed

8.Has applicant, to your knowledge, ever been guilty of:

 

 

(a) Fraud or dishonesty?

Yes

No

(b) Unprofessional conduct?

Yes

No

9. To your knowledge, has the applicant ever:

 

 

(a) been warned, censured, reprimanded, disciplined, had admissions monitored or privileges limited

 

 

or suspended?

Yes

No

(b) had disciplinary action taken against him/her by a licensing agency?

Yes

No

(c) been denied or surrendered a federal or state controlled substance permit?

Yes

No

(d) been arrested, fined, charged with or convicted of a crime, indicted, imprisoned

 

 

or placed on probation?

Yes

No

(e) been a defendant in a legal action involving professional liability (malpractice) or had a

 

 

professional liability claim paid in his/her behalf or paid such a claim him/herself?

Yes

No

(f) been placed on probation, asked to withdraw, or reprimanded?

Yes

No

(g) been terminated, resigned in lieu of termination or during investigation?

Yes

No

10.If you answered "yes" to any of the above questions, please provide any additional information you may have, including the names of other individuals who may have information concerning this applicant.

11.Are the dates of privileges provided by the applicant on the top portion of this form accurate?

฀ YES

฀ NO

12.If not, please provide the correct dates: Beginning month _____ / year ____Ending month _____ / year _______

Evaluating Physicians Name:

Printed

Signature

Date:

REMINDER: Evaluating Physician after completing this evaluation, place this form in an envelope of the hospital/institution that you represent, seal the envelope and place your signature over the outside sealed envelope flap. Send to:

Texas Medical Board PRC, MC-240 P.O. Box 2029 Austin, TX 78768-2029

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 06.14

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .