Form L For Texas Medical Board PDF Details

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QuestionAnswer
Form NameForm L For Texas Medical Board
Form Length3 pages
Fillable?Yes
Fillable fields80
Avg. time to fill out16 min 49 sec
Other namestexas l physician licensure verification, form l, form l template, physician evaluation verification

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FORM L

Physician Licensure Evaluation – Texas Medical Board

Verification of Postgraduate Training and Professional Evaluation

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.

This completed evaluation should be sent directly to the Texas Medical Board offices via mail, fax, or email.

By mail - 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, MC-240, P.O. Box 2029, Austin, TX 78768-2029

By fax - Evaluator must submit the form along with an official hospital/institution coversheet to 888-790-0621. Fax submitted by the applicant and/or without the appropriate coversheet cannot be accepted.

By email - Evaluator must submit the form from an official hospital/institution email address to screen-cic@tmb.state.tx.us. Emails sent from the applicant or from a non-agency email address cannot be accepted.

Title:

 Chief of Staff

Evaluating Physician’s

 Department Chairman

 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 01.2020

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.

FOR TRAINING POSITIONS – Completion of the Verification of Post Graduate Training and the Verification of Professional History sections are required.

FOR NON-TRAINING POSITIONS – Only completion of the Verification of Professional History section is required.

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.

 

 

 

 

 

 

 

 

 

 

 

 

Department:

 

 

 

 

 

PROGRAM PARTICIPATION: (For

 

 

 

PGY: _______

 

 

___________________________________

 

 

 

training positions only)

 

 

 

___ Internship

 

 

From: ___/___/___

To: ___/___/___

 

 

 

Report incomplete postgraduate years

 

 

 

___ Residency

 

 

 

 

 

 

 

 

 

 

Credit received?

 

 

 

 

 

 

 

___ Fellowship

 

 

 

 

 

 

(PGY) separately from those that were

 

 

 

 

 

 

 

 

 

 

 

 

___ Research

 

 

Full

*Partial

in progress

 

 

 

successfully completed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the postgraduate year is currently in

 

 

 

 

 

 

*For partial credit– how many months?______

 

 

 

progress, report the expected completion

 

 

 

 

 

Department:

 

 

 

 

 

date in the “To” field.

 

 

 

 

 

PGY: _______

 

 

___________________________________

 

 

 

Report Internships, Residencies and

 

 

 

 

 

 

 

 

 

 

 

___ Internship

 

 

From: ___/___/___

To: ___/___/___

 

 

Fellowships separately. Use one section

 

 

 

 

 

 

 

 

___ Residency

 

 

 

 

 

 

 

 

per department.

 

 

 

 

 

 

 

Credit received?

 

 

 

 

 

 

 

 

 

___ Fellowship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ Research

 

 

Full

*Partial

in progress

 

 

 

 

 

 

 

 

 

 

 

 

*For partial credit– how many months?______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department:

 

 

 

 

 

 

 

 

 

 

 

 

PGY: _______

 

 

___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ Internship

 

 

From: ___/___/___

To: ___/___/___

 

 

 

 

 

 

 

 

 

 

___ Residency

 

 

Credit received?

 

 

 

 

 

 

 

 

 

 

 

___ Fellowship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ Research

 

 

Full

*Partial

in progress

 

 

 

 

 

 

 

 

 

 

 

 

 

*For partial credit– how many months?______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNUSUAL

 

 

 Yes  No

1.

 

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

 

 

 

CIRCUMSTANCES:

 

 

 Yes  No

2.

 

Did this individual resign from training?

 

 

 

 

(For training

 

 

 Yes  No

3.

 

Were any limitations or special requirements placed upon this individual for

 

 

 

positions only)

 

 

 

 

professionalism or behavioral issues?

 

 

 

 

 

Please attach an

 

 

 Yes  No

4.

 

Did this individual ever receive a written warning or documented counseling

 

 

 

 

 

 

 

 

about his/her behavior?

 

 

 

 

 

 

explanation for any

 

 

 

 

 

 

 

 

 

 

 

 

 

 Yes  No

5.

 

Was this individual ever placed on probation for any reason?

 

 

 

“yes” response.

 

 

 

 

 

 

 

 

 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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 01.2020

FORM L

Applicant's Name___________________________________________

 

Page 3

 

 

 

 

 

 

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

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

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.

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

 Yes

 No

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

Evaluating Physicians Name:

Printed

 

Signature

Date:

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 01.2020

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