Attachment 4 Full License Application Kit DRAFT~1.pdf

Full License Application – Important Information, Page 1 of 31, Rev. 5/19

Commonwealth of Massachusetts Board of Registration in Medicine 200 Harvard Mill Square, Suite 330 – Wakefield, MA 01880

Telephone: (781) 876-8210 Fax: (781) 876-8383 www.mass.gov/massmedboard

IMPORTANT INFORMATION FOR THE FULL LICENSE APPLICANT

Welcome to Massachusetts and thank you for choosing our state to practice medicine! This application is for U.S. and international medical school graduates applying for a full, administrative, or volunteer license in Massachusetts for the first time.

It is extremely important that you read and follow all instructions carefully. After receipt of your application, the Board will notify you via email about any additional documentation needed--this may take up to eight weeks. The Licensing Division staff reviews applications in the order they are received.

The Board strongly recommends that you do not make any commitments such as home purchases, loans, etc. until you have been granted a license to practice medicine in Massachusetts.

Important Notes Regarding the Licensing Process:

• The Board encourages you to be actively involved in the licensure process. Follow up with medical schools, training programs and liability carriers to ensure that information is provided promptly.

• All documents should be submitted as one-sided and must be legible.

• Complete the application fully and accurately. If you are using a licensing service, carefully review your application prior to its submission to ensure its accuracy. You are personally responsible for all information disclosed on your application, including any responses that may have been completed on your behalf by others.

• Honestly and fully answer all questions. Your responses are evaluated as evidence of your character and fitness to practice.

• Please be advised that a false response to an application question may be grounds for denial of licensure and reported to the appropriate data banks.

• It is your responsibility to notify the Board if your response to any question changes while your application is pending. You must immediately notify the Board of the new information.

• Documents must be current within 6 months of the date of license approval. Please ensure that the information you provide is current and all documents are signed/dated just prior to submission.

• Questions should be directed to the Licensing Analyst assigned to your application.

• Please refer to the Application Instructions posted on the Board’s website for additional information.

HOW SOON CAN I GET A FULL LICENSE?

The answer depends on two factors:

1) whether you have submitted all required documentation in accordance with the Board’s regulations; and

2) the current volume of applications being processed by the Licensing Division staff.

A full license application cannot be deemed complete until all of the required documentation is received and reviewed by the Board. Typically, a full license application, received from August through December, can be issued in approximately twelve (12) weeks if there are no legal, competency or moral character issues. Similar license applications received between January and July may take approximately sixteen (16) weeks to process due to the larger volume of applications received at that time.

http://www.mass.gov/massmedboard

PRINT NAME: __________________________________________________________________________________

Full License Application - Checklist, Page 2 of 31, Rev. 5/19

FULL LICENSE APPLICATION CHECKLIST

Listed below are the minimum application and supporting materials required to obtain a full license in Massachusetts. This list is not all-inclusive; additional items may be necessary based on responses provided on your Application or information obtained from other sources. For further information please see the Full License Application Instructions posted on the Board’s website: www.mass.gov/massmedboard.

Please confirm that documents listed on this checklist are included with your full license application.

INFORMATION REQUIRED FROM APPLICANT

□ Application Fee

• Check for $600.00 o Must be from a U.S. bank (or a U.S. money order).

o Made payable to the Commonwealth of Massachusetts.

o Application cannot be processed without the fee.

o Application fee is non-refundable.

□ Full License Application

• All fields completed and all questions answered.

• Timeline from date of medical school graduation to the present, including all professional and non-professional activities with no gaps of 30 days or more.

• “Yes” answers to any Application Question (#21 – 51) requires an explanation on the appropriate Explanation page and submission of supporting documentation, where required.

• Recent 2 inch x 2 inch color photo attached and notarized by a U.S. notary.

• Application signed and dated.

• Complete a Name Change Form (available on website) if any other names appear on your documents such as medical education, exams scores, etc.

□ CORI Acknowledgment Form

• Must be notarized by a U.S. notary.

• All fields with an asterisk are mandatory.

• As part of the general background check for licensing purposes, the Board must receive Criminal Offender Record Information (“CORI”) from the Massachusetts Department of Criminal Justice Information Systems prior to the issuance of a full license.

□ Liability Carrier Request

• Only required if you have ever held a full license to practice medicine in the U.S. or Canada.

• You must submit the Original Liability Carrier Request Form listing ALL liability carriers, in chronological order, beginning from the date that your first full license was issued in any state to the present.

• Provide copies of his Form to each liability carrier in order to request a claim history report.

• Include the liability carrier for your postgraduate training only if you had a full license or were named in a malpractice claim during that time.

□ Curriculum Vitae (CV) • Submit a current CV (no formatting requirements).

Personal Interview (if applicable) • You will be notified if a personal interview will be required.

Full License Application – Checklist, Page 3 of 31, Rev. 5/19

DOCUMENTS REQUIRED FROM THIRD PARTIES

All documents from third parties must be received as indicated below. Do not open the sealed envelopes.

Asterisk(*) denotes that the sealed envelope must have the facility seal or signature on the back of the envelope.

□ Examination Scores from the Appropriate Examination Entity

(sealed envelope or FCVS)

• Official examination scores must be requested from the appropriate examination agency. Official examination reports may be requested from the following:

o USMLE, FLEX – www.fsmb.org o COMLEX – www.nbome.org o NBME – www.nbme.org o LMCC (Canada) – www.mcc.ca o State Board Examination – acceptable if taken prior to June 19, 1970.

□ Supervisory Evaluation

(*sealed envelope)

• Completed by a supervising physician (e.g. CMO; Department Chair; or physician who evaluates your clinical activities).

• If currently in training it must be completed by a Program Director.

• The evaluator must have no financial interest in your licensure.

• Evaluations must cover at least one year of current clinical activities. If you have been practicing at a facility for less than one year, you must request additional Evaluation Forms from previous supervisors to cover a full year.

• Locum tenens physicians must have evaluations from the most recent two years of assignments.

• May be completed by the same physician that completes the Certificate of Moral and Professional Character.

□ Certificate of Moral and Professional Character

(*sealed envelope)

• Completed by a licensed physician in the U.S. who has known you for at least one year and is not a relative.

• May be completed by the same physician that completes the Supervisory Evaluation Form.

□ Medical Education Verification

(*sealed envelope or FCVS)

• Primary source verification is required from ALL medical schools of attendance.

• Either complete the Board’s Medical Education Verification - Form A or submit verification of your medical education through FCVS.

• If you have ever held a Limited License in Massachusetts, your Medical Education Verification does not need to be resubmitted.

□ Postgraduate Training Verification

(*sealed envelope or FCVS)

• To be eligible for a full license, U.S. medical graduates must have satisfactorily completed two years of ACGME, AOA or Canadian accredited training.

International medical graduates must have satisfactorily completed three years of ACGME, AOA or Canadian accredited training. If you do not meet these requirements, please see the Instructions for information regarding eligibility.

• Primary source verification is required of ALL postgraduate training, regardless of whether the training was completed and/or was accredited.

• Either complete the Board’s Postgraduate Training Verification Form or submit verification of your postgraduate training through FCVS.

• Form must be completed by postgraduate training program director or an authorized agent.

• Postgraduate training verification is required even if you are currently completing or previously completed training in Massachusetts under a Limited License.

• For purely research postgraduate training, provide a letter of good standing from the program/research director detailing the beginning and end date of training. (sealed envelope).

http://www.fsmb.org/ http://www.nbome.org/ http://www.nbme.org/ http://www.mcc.ca/

Full License Application – Checklist, Page 4 of 31, Rev. 5/19

□ AMA or AOA Physician Profile

(sealed envelope or electronically)

• Request that either one of the following be submitted to the Board:

o AMA Physician Profile (https://commerce.ama-assn.org/amaprofiles/); or o AOA Osteopathic Physician Profile (www.osteopathic.org)

□ National Practitioner Data Bank (NPDB)

(sealed envelope)

• Request a paper copy of your self-query profile from the NPDB at www.npdb-hipdb.hrsa.gov

• Do not open the envelope when you receive the paper copy of your NPDB profile. You must mail it directly to the Board.

□ Liability Carrier Claims History Reports

(directly from liability carrier or sealed envelope)

• Only required if you have ever held a full license to practice medicine in the U.S. or Canada.

• Request submission of a Claims History Report/Loss Run Report from every liability carrier listed on your Liability Carrier Request Form.

□ License Verifications

(sealed envelopes; electronically from licensing authority)

• License Verifications are required of every active or inactive full medical license issued to you in the U.S., Puerto Rico or Canada.

• Do not submit verification of training or temporary licenses.

INTERNATIONAL MEDICAL GRADUATES ONLY

□ ECFMG Certification:

(electronically or FCVS)

• Request submission of your ECFMG Status Report (www.ecfmg.org)

□ Medical School Transcript

(sealed envelope)

• An official medical school transcript prepared on university letterhead affixed with the signature of the dean or registrar.

• If the medical education transcript is not in English, it must be translated either by your medical school or a U.S. translations company.

• The transcript must be mailed directly from the medical school to the Board or received in a sealed envelope to be acceptable.

□ Medical School Diploma

(provided by applicant, medical school or FCVS)

• A notarized (U.S. Notary) copy of your medical school diploma is required.

• If the medical school diploma is not in English, it must be translated either by your medical school or a U.S. translation company.

□ Substantial Equivalency of Medical Education and Off- Site Rotations Waiver Request (if applicable)

• This applies ONLY to applicants who completed more than three (3) months of clinical clerkship rotations outside of the primary teaching hospital of their medical school of attendance.

• If applicable, you must submit the following documents:

o Substantial Equivalency Waiver Request (completed by applicant);

o E-1 Form (send to medical school for completion); and o E-2 Form (send to each facility where you completed a clinical clerkship. E-2 Forms must be received in a sealed envelope).

• The Board has determined that following medical schools are substantially equivalent to U.S. medical school training. Graduates of these schools DO NOT need to complete a Waiver Request or Forms E-1 and E-2.

o St. George’s University School of Medicine;

o SABA University;

o Ross University School of Medicine; and o The American University of the Caribbean.

https://commerce.ama-assn.org/amaprofiles/ http://www.osteopathic.org/ http://www.npdb-hipdb.hrsa.gov/ http://www.ecfmg.org/

Full License Application, Page 5 of 31, Rev. 5/19

FULL LICENSE APPLICATION

Non-refundable Application Fee: A $600.00 check or money order payable to the Commonwealth of Massachusetts must be included with your full license application.

TYPE OF APPLICATION

(Check One)

Initial Full License

Administrative License

Volunteer License

(Check One)

U.S. or Canadian Medical School Graduate

International Medical School Graduate

FCVS Are you submitting primary source documentation (medical education, previous postgraduate training, etc.)

for licensure through FCVS? Yes No

PERSONAL INFORMATION

1. Legal Name Last First Middle Suffix

2. Other Name(s) List other names that appear on your application documents (medical education, exams, etc.)

3. Degree Type M.D. D.O. Other degree: __________________________________

4. Social Security Number

5. Gender Male Female

6. NPI Number

7. Date of Birth

Month Day Year

8. Place of Birth

City/State Country if not USA

9. Mailing Address

This address will be used for correspondence

Number and Street

City State/Province/Territory Zip (or postal) Code

10. Home Address

11. Business Address

12. Telephone Numbers Home # Business # Cell #

13. Email Address

Will be used for correspondence

200 Harvard Mill Square, Suite 330 - Wakefield, MA 01880

PRINT NAME: ___________________________________________________________________________________

Full License Application, Page 6 of 31, Rev. 5/19

Questions #14 – 16 are optional. This information will assist the Board in processing your application.

14.

Reason for requesting a Massachusetts medical license: ____________________________________________

15.

Name of anticipated practice location/facility: ____________________________________________________

Address: _______________________________________________ City: ________________________________

16.

Anticipated starting date in Massachusetts: ________/________/__________

U.S. OR CANADIAN MEDICAL LICENSURE

17.

If you currently or have ever held a full license in the U.S. or Canada list the state/province abbreviation.

This includes any active or inactive licenses. Do not report training or temporary licenses.

NOTE: You must provide license verifications for every active or inactive full license issued to you in the U.S.

or Canada. Verifications must be received in a sealed envelope, electronically from the licensing authority or through Veridoc.

PRACTICE SPECIALTY

18.

List the medical specialt(ies) that you practice. If you are completing postgraduate training, list that specialty here. The specialties listed will be included on your Physician Profile on the Board’s website to help consumers locate physicians in specific specialties.

ABMS/AOA BOARD CERTIFICATION

19.

Are you certified by the American Board of Medical Specialties (ABMS)? Yes No

If “Yes”, list Board Certification(s):__________________________________________________________

20.

Are you certified by the American Board of Osteopathic Medicine (AOA)? Yes No

If “Yes”, list Board Certification(s): __________________________________________________________

Full License Application, Page 7 of 31, Rev. 5/19

EXAMINATION HISTORY

Please note below each medical licensure examination you have taken.

NOTE: Please contact the appropriate entity and have the exam scores sent to you in a sealed envelope or sent electronically to the Board. If you are using FCVS, your exam scores will be sent to the Board directly.

The Board requires that all Steps of the USMLE and all levels of the COMLEX must be completed within 7 years and that Step3/Level 3 be completed within 3 attempts. If you do not meet either of these requirements, please see the Instructions for information regarding eligibility.

Examination

USMLE Step I

USMLE Step II CK

USMLE Step II CS

USMLE Step III

NBME Part I

NBME Part II

NBME Part III

FLEX Component 1

FLEX Component 2

FLEX Pre-1985

COMLEX Level 1

COMLEX Level 2

COMLEX Level 3

MCCQE – Part I

MCCQE – Part II

State Board Exam

Number of attempts

State of Examination: ___________

Passed (P) or Failed (F)

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

Full License Application, Page 8 of 31, Rev. 5/19

PRE-MEDICAL SCHOOL

A minimum of two or more academic years at a legally-chartered college or university is required.

For international medical graduates, this education may be incorporated into your medical school training. If not, please indicate the school(s) where you completed this requirement.

Name of School

Degree Dates of Attendance (Year)

__________ To __________ City State/Country

Name of School

Degree Dates of Attendance (Year)

__________ To __________ City State/Country

MEDICAL SCHOOL

List all medical schools of attendance regardless of whether a degree was awarded.

Medical School Name

Degree

Street

City, State

Full License Application, Page 9 of 31, Rev. 5/19

TIMELINE OF ACTIVITIES SINCE GRADUATION FROM MEDICAL SCHOOL

Please provide a chronological listing by month and year of ALL activities since graduation from medical school.

You must include postgraduate training, research activities, hospital affiliations, medical staff appointments, faculty appointments, private practices, locum tenens and telemedicine assignments and any other employment or volunteer activities. Also include periods of unemployment or any activities outside of the practice of medicine. Do not write, “See CV” or “See attached”; you must complete this section AND attach your curriculum vitae. If you need additional rows, please print additional copies of this page. You MUST account for any time gaps of 30 days or more since your graduation from medical school. (For example, if you graduated from medical school on May 31, 2015 and started residency on July 1, 2015, you must account for this gap of 30 days.)

Start Date (mm/yyyy)

End Date (mm/yyyy)

Position Held (Resident, Attending, Research

Fellow, etc.)

Institution/Place of

Employment City, State/Country

Month Year Medical School Graduation Date (start timeline from this date)

Full License Application, Page 10 of 31, Rev. 5/19

APPLICATION QUESTIONS

You must answer “yes” or “no” to questions #21 – 46.

NOTE: A “yes” response requires a detailed explanation on the Explanation for Application Questions page and submission of documentation related to the underlying occurrence from the appropriate institution.

PRE-MEDICAL SCHOOL AND MEDICAL SCHOOL YES NO

21. While enrolled in college, medical school or graduate school were you ever the subject of any disciplinary action?

(This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.)

22.

Have you ever been terminated from a medical school?

23. Have you ever withdrawn or transferred from a medical school?

24. Have you ever been granted a leave of absence by a medical school?

(This includes a leave for research, public service, participated in a joint degree program such as an M.D./Ph.D. program, medical leave or for any other “personal reasons”.)

25. Have you ever been placed on probation or remediation by a medical school or graduate school?

26. If you are a US or Canadian graduate, did you take more than four (4) years to complete medical school; or if you are an international medical graduate, did you take more than six (6) years to complete medical school?

POSTGRADUATE TRAINING YES NO

27. While enrolled in postgraduate training were you ever the subject of any disciplinary action or under investigation?

(This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.)

28. Have you ever been suspended, terminated or dismissed from any postgraduate training program?

29. Have you ever had to repeat a year of postgraduate training?

30. Have you ever withdrawn or transferred from a postgraduate training program?

31. Have you ever been granted a leave of absence from a postgraduate training program?

(This includes a leave for research, public service, medical leave or for any other “personal reasons”.)

32. Have you ever been placed on probation or remediation by a postgraduate training program?

33. Were any limitations or special requirements imposed on you because of questions of competency or disciplinary problems?

34. Did you ever receive partial or no credit for a postgraduate training program?

35. Have you ever had a postgraduate training program contract not be renewed?

Full License Application, Page 11 of 31, Rev. 5/19

ACTIONS BY ANY HEALTHCARE FACILITY, EMPLOYMENT, PROFESSIONAL

ORGANIZATION, STATE BOARD OR ANY OTHER GOVERNMENTAL AGENCY YES NO

36. Have you been denied the privilege of taking or finishing an examination or been accused of or found to have cheated or engaged in improper conduct during an examination?

37.

Have you ever been denied a medical license, whether full, limited, temporary, or have you withdrawn an application for medical licensure?

38. Have you ever surrendered a license to practice medicine or any professional license or has your license or certificate ever been revoked?

(You do not need to report a lapsed license.)

39. Have you been denied American Board of Medical Specialties or American Board of Osteopathic Medicine certification or has your certification ever been suspended or revoked?

40. Are you aware of any pending investigation or inquiry into your professional conduct by any entity or are any disciplinary charges pending against you?

41. Since your completion of postgraduate training, has any disciplinary action ever been taken against you?

(A confidentiality agreement does not absolve you of your requirement to answer this question.)

42. Has your medical staff membership, medical privileges, medical staff status or association with a health care facility ever been limited, suspended, revoked, not renewed or subject to probationary conditions or has processing toward any of those ends been instituted or recommended by a medical staff committee, administration or governing board?

43. Have you ever withdrawn an application for hospital privileges or appointment, or have you ever been denied medical staff membership, advancement in medical staff status or association with a health care facility, or has such denial been recommended by a medical staff committee, administration or governing body?

44. Has your privilege to manufacture, distribute, administer, possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, restricted or surrendered, or have you ever been called before or warned by any state or other jurisdiction including a federal agency regarding such privileges?

45. Has any professional liability insurance provider ever restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition on your coverage or have you ever voluntarily restricted, limited or terminated your insurance coverage in response to any inquiry by a professional liability insurance provider?

46. Have you ever had an application for membership as a participating provider denied by any third-party payor, Medicare or Medicaid (any state) or have you ever been the subject of any termination, suspension or probation proceedings instituted by any third-party payor, Medicare or Medicaid (any state) or have you ever been restricted from receiving payments from any third-party payor, Medicare, Medicaid (any state)?

Full License Application, Page 12 of 31, Rev. 5/19

EXPLANATION FOR APPLICATION QUESTIONS

This form must be used to provide a detailed written explanation for a “yes” response to Questions # 21 - 46 on the application. Please use as many forms as necessary to provide a detailed explanation.

Do not write, “See attached;” you must provide your response on this form.

A separate form is to be used for each question.

SUPPORTING DOCUMENTATION: In addition to the below explanation, you must arrange for the appropriate agency or institution to submit copies of all official documentation related to any “yes” response to a question on the Application. Documentation should be sent directly to the Board or to you in a sealed envelope.

Application Question Number: ________________ (List the corresponding question number - # 21 - 46)

Name of agency or institution taking action: ________________________________________________________

Date(s): ______ /______ /_________ - ______ /______ /_________

Please provide a detailed explanation: ____________________________________________________________________

Full License Application, Page 13 of 31, Rev. 5/19

MEDICAL MALPRACTICE HISTORY QUESTION

You must answer “yes” or “no” to question #47.

NOTE: A “yes” response requires a detailed explanation of each malpractice claim. Please use the

Explanation for Malpractice History Question. You must also arrange for your lawyer or liability carrier to provide the requested supporting documentation.

YES NO

47. Has any medical malpractice claim ever been made against you, whether or not a lawsuit was filed in relation to the claim?

NOTE: You must report any medical malpractice claims that have been made against you, even if the claim against you was dropped, dismissed, settled, adjudicated or otherwise resolved.

CRIMINAL HISTORY QUESTION

You must answer “yes” or “no” to question #48.

NOTE: A “yes” response requires a detailed explanation of each offense/arrest. Please use the

Explanation for Criminal History Question. You must also arrange for submission of the court and police records directly from the primary source or from your lawyer.

YES NO

48. Have you ever been charged with any criminal offense?

NOTE: You must report being arrested, arraigned, indicted or convicted, even if the charges against you were dropped, filed, dismissed or otherwise discharged. Minor traffic or parking violations need not be reported. You must report serious traffic offenses such as reckless driving, hit and run, driving with a suspended license, or operating under the influence or its equivalent.

This list is not all-inclusive. If in doubt as to whether an arrest or criminal offense must be disclosed, it is best to disclose the action on your application. A medical malpractice claim is a civil, not a criminal matter and should not be reported on this question.

Expunged/Sealed Offenses: While expunged/sealed offenses, arrests, tickets or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact been expunged or sealed. Failure to reveal an offense, arrest, ticket or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. You may have been told your record is expunged or sealed when in fact it is not. If, during the course of the application process, information about an offense is discovered which you did not disclose because you believed it to be expunged or sealed, you will be required to provide a copy of the expunction or sealing order.

Full License Application, Page 14 of 31, Rev. 5/19

EXPLANATION FOR MALPRACTICE HISTORY QUESTION

This form must be used to provide a detailed written explanation for a “yes” response to question #47 on the Application. Please use as many forms as necessary to provide a detailed explanation.

A separate form is to be used for each malpractice claim.

SUPPORTING DOCUMENTATION: In addition to the below explanation, you must arrange for your lawyer or liability carrier to provide the following documents directly to the Board or to you in a sealed envelope:

Pending Claim: 1) malpractice history report from your liability carrier or letter from your attorney that includes the claimant’s name/initials and confirmation that the claim is open/pending; and 2) a copy of the Complaint, Notice of Intent to File a Claim or other claim letter.

Closed Claim: 1) malpractice history report from your liability carrier or letter from your attorney that includes the claimant’s name/initials and confirmation that the claim is closed; 2) a copy of the Complaint, Notice of Intent to File a Claim or other claim letter; and 3) a copy of the final judgment, settlement and release or other final disposition of the claim, even if you were dismissed from the case by the court.

GENERAL CLAIM INFORMATION:

Claimant’s name/initials:

Date of incident: ________/________/_________

Professional Liability Carrier:

Legal representative’s name:

STATUS OF CLAIM:

Current status of claim: Closed Pending

Was a lawsuit filed in relation to the claim: Yes No

If the claim resulted in a lawsuit, what was the final outcome of the suit?

Dismissed before trial Judgment for Defendant Judgement for Plaintiff

Other (please specify) ______________________________________

Was the claim settled by you or on your behalf? Yes No

If a payment was made on your behalf, either as a result of a settlement or an award of damages:

Amount allocated to you: $_______________________________________

(Explanation for Malpractice History Question continued on the next page)

Full License Application, Page 15 of 31, Rev. 5/19

MALPRACTICE EXPLANATION CONTINUED

MALPRACTICE CLAIM DESCRIPTIVE INFORMATION:

Allegation(s):

Alleged Patient Injury:

Condition of Patient When You Began Treatment:

Condition of Patient at the End of Treatment:

Detailed Summary: Provide a detailed narrative of the clinical course and circumstances leading to the claim, including the nature and extent of your involvement and role in patient the care.

Full License Application, Page 16 of 31, Rev. 5/19

EXPLANATION FOR CRIMINAL HISTORY QUESTION

This form must be used to provide a detailed written explanation for a “yes” response to question #48 on the Application. Please use as many forms as necessary to provide a detailed explanation.

A separate form is to be used for each criminal offense/arrest.

SUPPORTING DOCUMENTATION: In addition to the below explanation, you must arrange for the following to be sent directly to the Board or to you in a sealed envelope:

1) Court Records: The appropriate court or your lawyer must send certified copies of all court records related to the offense; and 2) Police Records: The appropriate arresting/ticketing agency or your lawyer must send certified copies of the arrest/offense/incident report or citation/ticket.

*If a court, an arresting/ticketing agency or your lawyer is unable to provide copies of the applicable records, request that they furnish a written statement to that effect.

Incident Date: ______/______/________ Location of Incident (City and State/Country): ___________________________________________________ Arresting/Ticketing Agency: __________________________________________________________________ Court: _____________________________________________________________________________________ Initial Charge(s): ____________________________________________________________________________ _____Misdemeanor ______ Felony Final Charge(s): _____________________________________________________________________________ _____Misdemeanor ______ Felony Plea: ______________________________________________________________________________________ Disposition: (if probation, deferred adjudication, or deferred prosecution give summary.)

Detailed Summary. Provide a personal statement containing a detailed summary of the events and circumstances leading to the criminal offense:

Full License Application, Page 17 of 31, Rev. 5/19

CONFIDENTIAL INFORMATION QUESTIONS

For purposes of the following questions, “currently” does not mean on the day of, or even the weeks or months preceding the completion of this application. It means recently enough to have an impact on one’s functioning as a licensee, or within the past two years. You must answer “yes” or “no” to questions #49 - 51.

NOTE: A “yes” response to questions # 49 - 51 requires a detailed explanation. Please use the Explanation for Confidential Information Questions.

YES NO

49. Do you have a medical or physical condition that currently impairs your ability to practice medicine?

50. Have you engaged in the use of any substance(s) with the result that your ability to practice medicine is currently impaired?

51. Have you ever refused to submit to a test to determine whether you had consumed and/or were under the influence of chemical substances?

** IMPORTANT NOTE REGARDING PHYSICIAN WELLNESS **

If you have a substance use disorder or mental or physical health diagnosis that impacts your ability to practice medicine, the Board encourages you to seek assistance voluntarily and to abide by any recommendations of your health care provider.

When the Board receives notice of a substance use disorder, its primary mission is to protect the public; however, the Board also seeks to ensure successful rehabilitation through the physician’s participation in approved treatment programs and supervised structured aftercare. Similarly, when the Board receives notice of a mental health or physical health diagnosis that impacts a physician’s ability to practice, the Board needs to ensure that the physician can practice medicine safely.

In regard to issues of physician impairment, whether the impairment is caused by a substance use disorder, or a mental or physical health diagnosis, the Board works cooperatively with the Massachusetts Medical Society’s Physician Health

Services (PHS) and encourages physicians to contact PHS to determine what services may be available to them in order to ensure their safe practice of medicine. Please call PHS at (781) 434-7404.

PHS is a nationally recognized physician assistance program designed to assist physicians with the following: alcohol misuse; substance use disorder; behavioral or mental or physical health issues that currently impair the ability to practice medicine; stress including administrative burdens; financial pressures; and work-family balance issues. PHS does not treat but may refer a physician for evaluation and treatment, if necessary. PHS services are available to all physicians in Massachusetts, whether or not they belong to the Massachusetts Medical Society.

Full License Application, Page 18 of 31, Rev. 5/19

EXPLANATION FOR CONFIDENTIAL INFORMATION QUESTIONS

QUESTION #49 – Medical or physical condition.

Please provide the specifics of your condition and any related treatment, including dates and diagnoses. In addition, provide any adjustments or interventions you may have made or taken to ameliorate or address the impact of your medical condition on your current practice, including a change of specialty or field of practice, or participation in any supervised rehabilitation program, professional assistance or retraining program, or monitoring program.

QUESTION #50 – Substance use.

If you have obtained medical treatment related to your use of substances, please provide the specifics of your treatment, including dates and diagnoses. In addition, provide any adjustments or interventions you may have made or taken to ameliorate or address the impact of your use of substances on your current practice, including participation in any supervised rehabilitation program or monitoring program.

QUESTION #51 - Refusal to take a screening test for chemical substances.

Please provide a description of the circumstances leading to your refusal to take the screening test and any resulting criminal or disciplinary consequences.

Full License Application, Page 19 of 31, Rev. 5/19

STATUTORY AND REGULATORY REQUIREMENTS FOR LICENSURE

NOTE: You must complete the following requirements. Please see the Instructions for further information.

52. Opioid and Pain Management Training: (You must check one.)

I completed three (3) credits of Board-approved CPD/CME credit in effective pain management.

(i.e., www.opioidprescribing.com)

I do not prescribe controlled substances (Schedules II – VI).

53. Child Abuse or Neglect Recognition and Reporting Training: (You must check one.)

I received training in child abuse and neglect assessment in medical school or postgraduate training.

I completed a hospital sponsored training program in recognizing the signs of child abuse and neglect.

I completed a CPD/CME program in identifying and reporting child abuse and neglect.

I completed an online training program (i.e. The Middlesex Children’s Advocacy Center’s program “51A Online Mandated Reporter Training: Recognizing and Reporting Child Abuse, Neglect and Exploitation” www.middlesexcac.org/51A-reporter-training).

I completed a specialized certification (i.e., Child Abuse Pediatrics)

54. Domestic and Sexual Violence Education and Training: (You must complete.)

I completed the Massachusetts Department of Public Health online training in Domestic and Sexual Violence for licensed healthcare professionals.

https://www.mass.gov/service-details/domestic-and-sexual-violence-integration-initiatives

55. MassHealth Enrollment Requirement: (You must check one.)

I am enrolled or have applied to enroll in MassHealth as a nonbilling provider.

(Nonbilling application: https://www.mass.gov/files/documents/2018/10/09/pe-nbp.pdf)

I am enrolled or have applied to enroll in MassHealth as a billing provider.

(Billing provider application must be requested through MassHealth at 1-800-841-2900)

56. Electronic Health Records (EHR) Proficiency Requirement: (You must check one.)

I have DEMONSTRATED PROFICIENCY in the use of EHR through my:

participation in a Meaningful Use program as an eligible professional.

my employment with, credentials to provide patient care at, or contractual agreement with an eligible hospital or critical access hospital with a CMS Meaningful Use program.

participation as either a Participant or an Authorized User in the Massachusetts Health Information Highway.

completion of 3 hours of a Category 1 EHR-related CPD/CME course that discusses, at a minimum, the core and menu objectives and the Clinical Quality Measures (”CQMs”) for Meaningful Use.

OR

I am EXEMPT from the EHR Proficiency requirement because I am an applicant:

for an Administrative or Volunteer License.

who will not be engaged in the practice of medicine as defined in 243 CMR 2.01(4).

on active duty as a member of the National Guard or of a uniformed service called into service during a national emergency or crisis.

http://www.opioidprescribing.com/ http://www.middlesexcac.org/51A-reporter-training https://www.mass.gov/service-details/domestic-and-sexual-violence-integration-initiatives https://www.mass.gov/files/documents/2018/10/09/pe-nbp.pdf

Full License Application, Page 20 of 31, Rev. 5/19

90-DAY RENEWAL INFORMATION

State law requires that renewal of your license occur on your first birthday after your license is issued, unless your birthday falls within ninety (90) days of your license issue date. If your first birthday is within the 90-day time period that your license is issued, you will not be required to renew your license until your following birthday.

Example: If your birthday falls on September 1, 2014, and your license is issued on July 1, 2014, your renewal date will be September 1, 2015. However, if your birthday falls on September 1, 2014, and your license is issued on January 1, 2014, you will be required to renew your license by your birthday on September 1, 2014. Renewals thereafter will be on a two-year birthday cycle.

Check one:

Do not hold my Full License Application; send it to the Board as soon as it is completed.

Hold my Full License Application until it is within the 90-day time period.

My birthday is: ________/_________/___________

CERTIFICATIONS

• Pursuant to M.G.L. c. 112, § 2 and 243 CMR 2.07(15), I certify that I will not charge to or collect from a Medicare beneficiary more than the Medicare “reasonable charge” for services, in compliance with Chapter 475 of the Acts of 1985. (Note: providing certification does not imply that you will participate in the Medicare program).

• Pursuant to M.G.L. c. 62C, § 49A, I certify under the penalties of perjury that, to the best of my knowledge and belief, I have filed any Massachusetts state tax returns and paid any Massachusetts state taxes that are required under law.

(Note: This applies even if you reside out of the state or out of the country.)

• Pursuant to M.G.L. c. 62C, § 49A, to the best of my knowledge and belief, I am in compliance with G.L. c. 119A relating to withholding and remitting child support.

• Pursuant to M.G.L. c. 119, § 51A, I certify under the penalties of perjury that I will fulfill my obligation to report abuse or neglect of children.

• By signing this application, I am providing my consent for the Massachusetts Board of Registration in Medicine and, where relevant, their supervising state agencies and the Massachusetts Executive Office of Health and Human Services, and where relevant, its provider enrollment vendor, to obtain, read, copy, and share with each other information regarding your MassHealth application and enrollment status and Massachusetts licensure status.

• I have read the Board’s regulations, 243 CMR 1.00 through 3.00.

Certification:

I confirm I have read and agree to comply with these statutory and regulatory requirements.

Full License Application, Page 21 of 31, Rev. 5/19

DECLARATION OF APPLICANT

I, _______________________________________________________________:

(PRINT LEGAL NAME)

being duly sworn, depose and say that I am the person described and identified in this application. I declare that I have examined this complete application and to the best of my knowledge and belief, the information contained herein and evidence or other credentials submitted herewith are true, correct and complete. I understand that any falsification or misrepresentation of any item or response on this application or any attachment hereto may be a sufficient basis for denying or revoking a license. I hereby request and authorize every person, institution, professional licensing board of any state in which I hold or may have held a license to practice my profession, hospital, clinic, government agency (local, state, federal or foreign), law enforcement agency, or other third parties and organizations and their representatives to release information, records, transcripts and other documents concerning my professional qualifications and competency, ethics, character and other information pertaining to me to the Massachusetts Board of Registration in Medicine. I hereby extend absolute immunity to and release, discharge, and hold harmless from any and all liability: 1) the Board of Registration in Medicine, its agents, representatives, directors and officers; 2) other agencies, institutions, hospitals and clinics providing information, their representatives, directors and officers; and 3) any third parties and organizations for any acts, communications, reports, records, transcripts, statements, documents, recommendations or disclosures involving me, made in good faith and without malice, requested or received by the Board of Registration in Medicine. I hereby authorize the Board of Registration in Medicine to transmit any information contained in the application, or information that may otherwise become available to them, to any agency, organization, or individual, who, in the judgement of the Board, has a legitimate interest in such information.

SIGNATURE: ______________________________________________ DATE: ______________________

PHOTOGRAPH

Photograph

Attach a recent 2 inch x 2 inch color photograph.

Black and white photographs will not be accepted.

SIGNATURE OF APPLICANT:

(Sign in the presence of a notary)

NOTARY SECTION

NOTARY: I certify that the photograph above is a genuine likeness of the marker of the signature above.

On this ______ day of _____________, 20____, before me, the undersigned notary public, personally appeared

____________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were ______________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

Signature of Notary Public

Commission Expires On

NOTARY SEAL

Full License Application – CORI Acknowledgment Form, Page 22 of 31, Rev. 5/19

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGMENT FORM

The Board of Registration in Medicine is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purpose of screening license applicants.

As a license applicant, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to the Board of Registration in Medicine to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing the Board of Registration in Medicine written notice of my intent to withdraw consent to a CORI check.

The Board of Registration in Medicine may conduct subsequent CORI checks within one year of the date this form was signed by me provided, however, that the Board of Registration in Medicine must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this Acknowledgment Form is true and accurate.

Signed under the penalties of perjury, this _____ day of _________________, 20 ____.

Signature of Applicant

Print Name

(Continued on next page)

(CORI Acknowledgement Form continued)

Full License Application – CORI Acknowledgment Form, Page 23 of 31, Rev. 5/19

SUBJECT INFORMATION: An asterisk (*) denotes a required field

*Legal Name

*Last *First Middle Suffix

*Maiden Name or other name(s) by which you have been known

*Date of Birth

*Place of Birth

*Last Six Digits of Your Social Security Number

Sex Height _______ft. _______in.

Eye Color Race

Driver’s License or ID Number

State of Issue

Mother’s Full Maiden Name

Father’s Full Name

Current and Former Addresses

Number and Street City/Town State Zip

Number and Street City/Town State Zip

NOTARY SECTION

On this ______ day of ____________________, 20_____, before me, the undersigned notary public, personally appeared

_____________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were ______________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

Signature of Notary Public

Commission Expires On

NOTARY SEAL

Full License Application – Supervisory Evaluation Form, Page 24 of 31, Rev. 5/19

SUPERVISORY EVALUATION FORM

APPLICANT INSTRUCTIONS: Complete this section and print your name on the top of the second page.

• This form must be completed by a supervising physician who can evaluate your clinical performance.

• If currently in training it must be completed by a Program Director.

• Evaluations must cover at least one year of current clinical activities. If you have been practicing at a facility for less than one year, you must request additional Evaluation Forms from previous supervisors to cover a full year.

• Locum tenens physicians must have evaluations from the most recent two years of assignments.

• The Evaluator must have no financial interest in your licensure in Massachusetts.

I hereby authorize the representatives or staff of the facility listed below to provide the Board of Registration in Medicine with any and all information requested in this evaluation form, whether such information is favorable or unfavorable, and I hereby release from any and all liability the named facility and/or any person for any and all acts performed in fulfilling this request, provided that such acts are performed in good faith and without malice.

Signature of Applicant:_________________________________________________ Date: _______/_______/_________

Applicant PRINT name:_____________________________________________________________________________

Name of Evaluating Hospital/Workplace:___________________________________________________ State: _______

SUPERVISING PHYSICIAN INSTRUCTIONS:

• Please complete both pages and return to the applicant with your name affixed across the envelope seal.

• The Board may provide a copy of this Form and any attachments to the applicant.

1. Date(s) of applicant’s affiliation at facility (month/year)? From: _____/_______ To: _____/_______

2.

In what capacity did you supervise the applicant? Department Chair Chief of Service

Training Director Supervising Physician Chief Medical Officer Medical Director

3. Applicant's Status: Intern Resident Fellow Staff Member Other: _________________

4.

Do you have any conflict of interest, personally, professionally or financially YES NO in recommending this applicant for licensure?

5. Please rate the applicant. If “Below Average” or “Poor”, explain in detail on a separate sheet.

Superior Above Average Average Below

Average Poor

Clinical knowledge Clinical competency Professional judgment Character and ethics Technical skills Relationships with staff Relationships with patients Cooperativeness/ability to work with others

PRINT NAME: _____________________________________________________________________________________ (Supervisory Evaluation Form continued)

Full License Application – Supervisory Evaluation Form, Page 25 of 31, Rev. 5/19

6.

Has the applicant's privileges to admit or treat patients ever been modified, suspended, reduced or revoked? If "yes" please explain below. YES NO

7. Has this applicant ever been the subject of disciplinary action or had staff privileges, employment or appointment at this hospital or facility…