Attachment 4 Initial Limited License Application Kit~1.pdf

Initial Limited Lic App (Instructions), Page 1 of 14, Rev. 1/19

Board of Registration in Medicine

200 Harvard Mill Square, Suite 330

Wakefield, MA 01880

Telephone: (781) 876-8210 Fax: (781) 876-8383

INITIAL LIMITED LICENSE APPLICATION INSTRUCTIONS

TABLE OF CONTENTS

GENERAL INFORMATION REGARDING LIMITED LICENSURE

INITIAL LIMITED LICENSE APPLICATION KIT

IMPORTANT NOTES

INITIAL LIMITED LICENSE APPLICATION INSTRUCTIONS

APPLICATION FEE

FEDERATION CREDENTIALS VERIFICATION PROFILE (FCVS)

LIMITED LICENSE APPLICATION SECTION A ................................................................. 1-10

SOCIAL SECURITY NUMBER

MASSACHUSETTS POSTGRADUATE TRAINING PROGRAM

PRE-MEDICAL EDUCATION

MEDICAL EDUCATION

POSTGRADUATE TRAINING

EXAMINATION REQUIREMENTS

MASSHEALTH ENROLLMENT

TIMELINE OF ACTIVITIES SINCE GRADUATION FROM MEDICAL SCHOOL

ACTIONS BY HEALTH CARE FACILITY, EMPLOYMENT

CRIMINAL HISTORY

MALPRACTICE HISTORY

CONFIDENTIAL INFORMATION

LIMITED LICENSE APPLICATION SECTION B

MEDICAL EDUCATION VERIFICATION FORM

SUPERVISORY EVALUATION FORM

MALPRACTICE HISTORY REQUEST FORM

STATE LICENSE VERIFICATIONS

ECFMG STATUS REPORT

J WAIVER FORM - SUBSTANTIAL EQUIVALENCY OF MEDICAL EDUCATION

TELEPHONE DIRECTORY & WEBSITE ADDRESSES

Initial Limited Lic App (Instructions), Page 2 of 14, Rev. 1/19

GENERAL INFORMATION

Limited Licensure: Limited licenses are issued to physicians enrolled in postgraduate medical education programs in healthcare facilities in the Commonwealth of Massachusetts. All such training must be done in either an ACGME-accredited or AOA-approved program, or in a fellowship program in a Massachusetts health care facility, which conducts on its premises ACGME or AOA approved programs. This information must be documented by the training program in Section B of this Limited License Application. A limited licensee may practice medicine only in the training program approved with their application.

Following Board approval of your limited license, your limited registration certificate verifying your registration number will be sent to your training program. That license number will be retained for the duration of that training program. If you enter a different training program (for example, change from a residency in general surgery to a fellowship in plastic surgery) at the same facility or another training program, you must submit a

Change of Program Application. A new license will be issued, assuming that you still qualify for limited license registration.

Please be advised that your limited license expires at the end of the academic year or earlier if your training is completed before the end of the academic year. If you are continuing in a training program, a limited renewal application must be completed and submitted to the Board at least 30 days prior to the end of the academic year.

The issuance of a limited license beyond a total of seven years of training may be granted only by a majority vote of the Board.

Previous Medical License in Massachusetts: If you ever held a full license in Massachusetts, do not use this application form. A physician who holds or who has ever held a full Massachusetts license is not eligible for a limited license.

Practice of Medicine: Please be advised that pursuant to Massachusetts laws and regulations, you may not practice medicine in a training program until you have received a license. Both the Physician and the participating training program are responsible for determining that the Board has issued a license prior to practicing medicine.

Application Processing Time/Review: The application review process is defined by the Board of Registration in

Medicine’s statutes, regulations and policies. The Board and its staff must comply with those requirements in processing applications. Following the submission of your application for licensure, the Board may, at any time, request additional documentation to determine the applicant’s compliance with the Board’s statutes and regulations. Applicants who are not in compliance with the Board of Registration in Medicine’s statutes and regulations may not be eligible for licensure. An application will not be deemed complete until all required application documents and verifications are received and reviewed by the Board and its staff.

Grounds for Denial: As an applicant, you are personally responsible for all information disclosed on your license application, including any responses that may have been completed on your behalf by others. An application may be denied based upon omission, falsification or misrepresentation of any item or response on the application or any supplemental documentation received in connection with your application. The

Massachusetts Board of Registration in Medicine considers violations of an ethical nature to be a serious breach of professional conduct.

Each applicant’s qualifications for licensure in Massachusetts are reviewed on an individual basis. The Board has the authority to deny licensure based upon an applicant’s failure to meet the Board’s requirements for licensure; failure to provide satisfactory proof of good moral character; or because of acts which, were they engaged in by a licensee, would violate M.G.L. c. 112, Section 5 or 243 CMR 1.03(5).

Initial Limited Lic App (Instructions), Page 3 of 14, Rev. 1/19

Interview: During the licensing process, you may be invited for a personal interview with the Board, and/or the

Licensing Committee regarding your license application. Unless otherwise indicated, all meetings of the Board or any of its Committees are held at the Board office at 200 Harvard Mill Square, Suite 330, Wakefield, Massachusetts.

Limited License Application Kit:

The Limited License Application Kit consists of the forms required for completing the application process. You may download additional forms at the Board’s website at www.mass.gov/massmedboard.

The Initial Limited License Application Kit is comprised of the following documents:

Initial Limited License Instructions

Initial Limited License Checklist

Initial Limited License Application, including Sections A and B as well as the supplemental pages if you answer “yes” to any of the questions

Authorization for Release of Information

Medical Education Verification form for premedical and medical education

Supervisory Evaluation Form (only if you have engaged in prior postgraduate training)

Malpractice History Request Form (only if you held a full license in another state or were named in a claim)

Name Change form (only if you have used other names which appear on your identifying documents)

Affidavit for Social Security number (only if you do not have a U.S. Social Security number)

The Board may, at any time, request additional documentation to determine the applicant’s compliance with the

Board’s statutes and regulations. Applicants who are not in compliance with the Board of Registration in

Medicine’s statutes and regulations may not be eligible for licensure.

Important Notes:

Read the accompanying instructions.

Provide a complete and accurate response for every question on the application and application forms.

Print legibly or type your answers.

All documents should be submitted as one-sided.

The Board requires that many documents be current within 6 months of the date of license approval;

therefore, please ensure that the information you provide is current and all documents are signed and dated just prior to submission.

http://www.mass.gov/massmedboard

Initial Limited Lic App (Instructions), Page 4 of 14, Rev. 1/19

INITIAL LIMITED LICENSE APPLICATION

Application Fee

The application processing fee for a limited license is $100.00 and is non-refundable. Please make your check payable to the Commonwealth of Massachusetts. A certified check or money order is preferred, but personal checks are accepted. An application cannot be processed without the fee.

U.S./Canadian Graduate

Graduates of medical schools in the United States, Canada or Puerto Rico, should follow the instructions for U.S.

graduates.

International Graduate

Graduates of all medical schools not located in the United States, Canada, or Puerto Rico, should follow the instructions for international medical graduates.

FCVS

The Massachusetts Board of Registration in Medicine accepts the FCVS (Federation Credentials Verification

Services) for verification of core credentials which includes medical school, postgraduate training, examination scores and ECFMG verification. If you choose to utilize FCVS, you may obtain information at www.fsmb.org or contact the FCVS at (817) 868-5000 or (888) 275-3287. The FCVS does not verify medical licenses in other states. Applicants utilizing FCVS for their core documents do not need to submit the following Board application forms/primary source documents:

Medical Education Verification Form

Postgraduate Training Verification Form

Examination Transcripts (USMLE)

ECFMC Verification

Applicants must complete all additional Board application forms and request all other primary source documentation to complete their application.

LIMITED LICENSE APPLICATION SECTION A

Section A of the Initial Limited License Application must be completed by the applicant, as well as any other corresponding forms. The applicant should forward the completed application (Section A and all supporting documentation) to the training program for review and completion of Section B.

1. Other Name(s)

If you used another name that appears on your identification documents, such as medical education and examination records, you must submit a notarized copy of your marriage certificate or a notarized copy of the court order changing your name. Please complete the Name Change and Duplicate License form and the Notary

Public Attestation for the Name Change form.

4. Social Security Number

Your social security number may be used to facilitate the authorized sharing of information with designated agencies for identification of licensees for the following purposes: reporting of disciplinary actions to national data repository systems; tax default status; student loan default status; child support arrearages; Medicaid provider eligibility; possession of Massachusetts controlled substances registration; and collection of fines imposed in connection with Board disciplinary cases. The Board considers this information highly confidential and not subject to release except as specifically authorized. If you do not have a Social Security number, you must complete the Affidavit form and include it with your Initial Limited License Application.

http://www.fsmb.org/

Initial Limited Lic App (Instructions), Page 5 of 14, Rev. 1/19

5. - 6. Mailing and Email Address

The Board will use your email and mailing address for all correspondence with you.

7. Massachusetts Postgraduate Training Program This is the name of the healthcare facility at which you will be practicing with your initial limited license. This information should correspond with the information in Section B.

8. Pre-medical School

A minimum of two (2) or more academic years at a legally-chartered college or university is required.

9. Medical School Four (4) academic years of instruction of not less than thirty-two (32) weeks in each academic year or courses which in the opinion of the Board of Registration in Medicine are equivalent, in a legally chartered medical school that grants the degree of doctor of medicine or its equivalent.

List all medical schools attended, regardless of whether a degree was issued.

#9-a. – f. College/Graduate/Medical School Questions

All applicants must complete Questions #9-a. – f. If you have any concerns on how to answer any of the questions in this section, please confirm with your educational institution on how to appropriately answer the question. The Board will confirm all answers with the primary source. For every “yes” answer you must:

1) provide an explanation on the corresponding explanation page (page 10); AND

2) arrange for the appropriate agency or institution to submit copies of all official documentation related to the underlying occurrence or action. Documents should be sent either directly to the Board from the appropriate agency/institution or to you in a sealed envelope. If the documents are sent to you, the sealed envelopes must be included with your limited license application or sent directly to the Board unopened.

#9-a. Answer “yes” if you have ever been the subject of any disciplinary action while enrolled in college, medical school or graduate school. 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. If you answered “yes” please use the explanation page provided on page 10.

#9-b. Answer “yes” if you have ever been terminated from a medical school for any reason. If you answered

“yes” please use the explanation page provided on page 10.

#9-c. Answer “yes” if you have ever withdrawn or transferred from a medical school, regardless of the reason. If

#9-d. Answer “yes” if you have you ever been granted a leave of absence by a medical school, including a leave for research, public service, participation in a joint degree program such as an M.D./Ph.D. program, medical leave or for any other “personal reasons”. Please provide the dates and circumstances of the leave in your explanation.

If you answered “yes” please use the explanation page provided on page 10.

#9-e. Answer “yes” if you have ever been placed on probation or remediation by a graduate/medical school. If

#9-f. Answer “yes” if as an US/Canadian graduate you took more than four years to complete medical school.

Answer “yes” if as an international graduate you took more than six years to complete medical school. If you answered “yes” please use the explanation page provided on page 10.

10. Postgraduate Training

If you are either currently engaged in or previously engaged in postgraduate training in the U.S. or Canada, please respond affirmatively to Question 10, provide the requested information about the training program and answer

Initial Limited Lic App (Instructions), Page 6 of 14, Rev. 1/19

Questions 10-a. – i. If you have not participated in any postgraduate training in the U.S. or Canada, please respond negatively to Question 10 and go on to Question 11.

#10-a. – i. Postgraduate Training Questions

You must answer questions 10-a. – i. if you are currently or have previously been engaged in postgraduate training in the U.S. or Canada. If you have any concerns on how to answer any of the questions in this section, please confirm with your postgraduate training program on how to appropriately answer the question. The Board will confirm all answers with the primary source. For every “yes” answer you must:

1) provide an explanation on the corresponding explanation page (page 10); AND

2) arrange for the appropriate agency or institution to submit copies of all official documentation related to the underlying occurrence or action. Documents should be sent either directly to the Board from the appropriate agency/institution or to you in a sealed envelope. If the documents are sent to you, the sealed envelopes must be included with your limited license application or sent directly to the Board unopened.

#10-a. Answer “yes” if you have ever been the subject of any disciplinary action or under investigation while enrolled in postgraduate training. 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. If

#10-b. Answer “yes” if you have ever been suspended, terminated or dismissed from any postgraduate training program for any reason. If you answered “yes” please use the explanation page provided on page 10.

#10-c. Answer “yes” if you have ever had to repeat a year of postgraduate training for any reason. If you

#10-d. Answer “yes” if you have ever withdrawn or transferred from a postgraduate training program for any reason. If you answered “yes” please use the explanation page provided on page 10.

#10-e. Answer “yes” if you have ever been granted a leave of absence from a postgraduate training program, including a leave for research, public service, medical leave or for any other “personal reasons”. Please provide the dates and circumstances of the leave in your explanation. If you answered “yes” please use the explanation page provided on page 10.

#10-f. Answer “yes” if you have ever been placed on probation or remediation by a postgraduate training program. If you answered “yes” please use the explanation page provided on page 10.

#10-g. Answer “yes” if any limitations or special requirements were imposed on your because of questions of competency or disciplinary problems during postgraduate training. If you answered “yes” please use the explanation page provided on page 10.

#10-h. Answer “yes” if you ever received partial or no credit for time spent in a postgraduate training program. If

#10-i. Answer “yes” if you have ever had a postgraduate training program contract not renewed for any reason. If

11. Examinations Requirements

Applicants for a limited license must have passing scores on USMLE Step 1 and Step 2 (CK and CS), or the first two levels of COMLEX, or all parts of MCCQE (LMCC).

The Board will accept a copy of the USMLE scores, COMLEX, or MCCQE if they were part of the ERAS application that was sent directly from the original source to the training program. The exam report should be sent to the Board by the Graduate Medical Education staff with the initial limited license application. Otherwise, exam scores for USMLE may be obtained from the Federation of State Medical Boards (FSMB) at

Initial Limited Lic App (Instructions), Page 7 of 14, Rev. 1/19 www.fsmb.org or the National Board of Osteopathic Medical Examiners for COMLEX at www.nbome.org or the Medical Council of Canada at www.mcc.ca for the MCCQE. NOTE: If you completed USMLE Step 2, CS or CK after the ERAS report was sent to your training program, you must request your USMLE scores from the

FSMB to be sent to your training program.

Examination scores from applicants will not be accepted unless they were sent to the applicant from the primary source in a sealed envelope. If your examination scores were not sent directly to your training program by ERAS, you then must request them in a sealed envelope and include them with your limited license application.

12. MassHealth Enrollment

Physicians (including interns and residents) are eligible to order, refer or prescribe services for MassHealth members and, under state law, must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure. Providers who are already enrolled with MassHealth have already met the requirement and do not need to take further action.

MassHealth has created a Nonbilling Provider Application for providers in provider types that are not eligible to enroll as fully participating providers. This application can also be used by providers who are eligible to enroll in

MassHealth as fully participating providers but who choose not to at this time. Physicians must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure. Providers who are already enrolled with MassHealth have already met the requirement and do not need to take further action.

Providers who wish to apply to enroll as nonbilling providers must download the materials from the MassHealth website at http://www.mass.gov/eohhs/docs/masshealth/aca/pe-nbp-con.pdf and send their completed and signed

Nonbilling Provider Application and Nonbilling Provider Contract by mail to the MassHealth Customer Service

Center at:

MassHealth Customer Service Center

Attn: Provider Enrollment and Credentialing

P.O. Box 121205

Boston, MA 02112-1205

Providers who have questions, or if eligible, would like to request a fully participating provider application should contact the MassHealth Customer Service Center at 1-800-841-2900 with any questions or, if eligible, to request a fully participating provider application.

13. Out-of-State Licensure

List all states where you ever had a full, license, whether the license is active, inactive or not renewed. If none, please check the appropriate box.

14. Curriculum Vitae (CV)

If one or more years have passed since the date of your graduation from medical school, answer affirmatively to

Question 14 and submit a current curriculum vitae (CV).

15. Timeline of Activities since Graduation from Medical School

You must complete this section if more than 30 days has passed since the date of your medical school graduation.

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 1, 2019 and sign and date your application June 3, 2019, you must complete the timeline to account for this gap of over thirty days.)

Provide a chronological listing by month and year of all activities since graduation from medical school. This includes all postgraduate training, research activities, hospital affiliations, medical staff appointments, locum http://www.fsmb.org/ http://www.nbome.org/ http://www.mcc.ca/ http://www.mass.gov/eohhs/docs/masshealth/aca/pe-nbp-con.pdf

Initial Limited Lic App (Instructions), Page 8 of 14, Rev. 1/19 tenens 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”.

16. – 26. Actions by Any Health Care Facility, Employment, Professional Organization, State Board or Any

Other Governmental Agency Questions

If you have any concerns on how to answer any of the questions in this section, please confirm with the appropriate facility/organization/agency on how to appropriately answer the question. The Board will confirm all answers with the primary source. For every “yes” answer you must:

3) provide an explanation on the corresponding explanation page (page 10); AND

4) arrange for the appropriate agency or institution to submit copies of all official documentation related to the underlying occurrence or action. Documents should be sent either directly to the Board from the appropriate agency/institution or to you in a sealed envelope. If the documents are sent to you, the sealed envelopes must be included with your limited license application or sent directly to the Board unopened.

#16. Answer “yes” if you have 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 this would include the time period beginning from college on through your professional career. If you answered “yes” please use the explanation page provided on page 10.

#17. Answer “yes” if you have denied a medical license, whether full, limited, temporary, or have you withdrawn an application for medical licensure for any reason. If you answered “yes” please use the explanation page provided on page 10.

#18. Answer “yes” if you have ever surrendered a license to practice medicine or any professional license or if your license or certificate has ever been revoked. For purposes of this question you do not need to report a lapsed license. If you answered “yes” please use the explanation page provided on page 10.

#19. Answer “yes” if you have been denied American Board of Medical Specialties or American Board of

Osteopathic Medicine certification or if your certification ever been suspended or revoked. If you answered “yes” please use the explanation page provided on page 10.

#20. Answer “yes” if you are aware of any pending investigation or inquiry into your professional conduct by any entity or if any disciplinary charges are pending against you. If you answered “yes” please use the explanation page provided on page 10.

#21. Answer “yes” if any disciplinary action has ever been taken against you since completing postgraduate training. A confidentiality agreement does not absolve you of your requirement to answer this question. If you answered “yes” please use the explanation page provided on page 10.

#22. Answer “yes” if your medical staff membership, medical privileges, medical staff status or association with a health care facility have ever been limited, suspended, revoked, not renewed or subject to probationary conditions or if processing toward any of those ends has been instituted or recommended by a medical staff committee, administration or governing board. If you answered “yes” please use the explanation page provided on page 10.

#23. Answer “yes” if you have withdrawn an application for hospital privileges or appointment, or have ever been denied medical staff membership, advancement in medical staff status or association with a health care facility, or if such denial has been recommended by a medical staff committee, administration or governing body. If you

#24. Answer “yes” if your privilege to manufacture, distribute, administer, possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, restricted or surrendered, or if you have ever been

Initial Limited Lic App (Instructions), Page 9 of 14, Rev. 1/19 called before or warned by any state or other jurisdiction including a federal agency regarding such privileges. If

#25. Answer “yes” if your professional liability insurance provider has ever restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition on your coverage or if you have ever voluntarily restricted, limited or terminated your insurance coverage in response to any inquiry by a professional liability insurance provider. If you answered “yes” please use the explanation page provided on page 10.

#26. Answer “yes” if you have ever had an application for membership as a participating provider denied by any third-party payor, Medicare or Medicaid (any state) or if you have ever been the subject of any termination, suspension or probation proceedings instituted by any third-party payor, Medicare or Medicaid (any state) or if you have ever been restricted from receiving payments from any third-party payor, Medicare, Medicaid (any state). If you answered “yes” please use the explanation page provided on page 10.

27. Criminal History Question

Answer “yes” if you have ever been charged with any criminal offense. This includes being arrested, arraigned, indicted or convicted, even if the charges against you were dropped, filed, dismissed or otherwise discharged. A charge of operating under the influence or its equivalent is reportable. A medical malpractice claim is a civil, not a criminal, matter and need not be reported for purposes of this question. If in doubt as to whether an arrest or criminal offense must be disclosed, it is best to disclose the action on your application.

If you answered “yes” please use the explanation page for question #27 located on page 11. A separate explanation page is to be used for each criminal incident. You must also arrange for the following supporting documentation 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.

If the criminal charge(s) against you have been formally expunged or sealed the charges, offenses, arrests, tickets or citations need not be disclosed for purposes of this question. However, 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.

28. Medical Malpractice History Question

Answer “yes” if any medical malpractice claim has ever been made against you, whether or not a lawsuit was filed in relation to the claim. This includes any medical malpractice claims that have been made against you, even if the claim against you was dropped, dismissed, settled, adjudicated or otherwise resolved or not pursued.

If you answered “yes” you must complete the explanation pages for question #28 located on pages 12-13. You must complete separate explanation pages for each malpractice claim. You must also 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.

Initial Limited Lic App (Instructions), Page 10 of 14, Rev. 1/19

29. - 31. Confidential Information Questions

For purposes of answering questions #29 – 31, “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 impact one’s functioning as a physician, or within the past two years. For every “yes” answer you must:

5) provide an explanation on the corresponding explanation page for that question; AND

6) arrange for the appropriate agency or institution to submit copies of all official documentation related to the underlying occurrence or action. Documents should be sent either directly to the Board from the appropriate agency/institution or to you in a sealed envelope. If the documents are sent to you, the sealed envelopes must be included with your limited license application or sent directly to the Board unopened.

#29. Answer “yes” if you have a medical or physical condition that currently impairs your ability to practice medicine. If you answered “yes” you must complete the explanation page for question #29 located on page14.

Your explanation of a “yes” answer should include 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.

#30. Answer “yes” if you engaged in the use of any substance(s) with the result that your ability to practice medicine is currently impaired. If you answered “yes” you must complete the explanation page for question #30 located on page14. Your explanation of a “yes” answer should include the specifics of your treatment, if any, 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.

#31. Answer “yes” if you have ever refused to submit to a test to determine whether you had consumed and/or were under the influence of chemical substances. If you answered “yes” you must complete the explanation page for question #31 located on page14. This would include, but is not limited to, refusal to submit to a breathalyzer test. If you answered “yes” your explanation should include a description of the circumstances leading to your refusal to take the screening test and any resulting criminal or disciplinary consequences.

**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.

Initial Limited Lic App (Instructions), Page 11 of 14, Rev. 1/19

LIMITED LICENSE APPLICATION SECTION B

Section B of the initial limited license application must be completed and signed by the designated official at the healthcare facility at which the applicant has received an appointment.

AUTHORIZATION FOR RELEASE OF INFORMATION, DOCUMENTS AND RECORDS FORM

Sign and date the Authorization for Release of Information, Documents and Records form.

MEDICAL EDUCATION VERIFICATION FORM

Complete the authorization statement at the top of the Medical Education Verification form and send it to your medical school. If more than one medical school was attended, the form must be duplicated and sent to each additional school.

If there were gaps in your medical education, or more than four (4) years of medical school for U.S graduates, or more than six (6) years for international medical school graduates, you must provide an explanation for the additional months or years and the medical school must also provide the dates and reason(s) for the additional months or years.

International medical schools must provide a copy of the medical school transcripts in English. If the transcripts are in a language other than English, the Board will send a copy of the medical school transcripts to you to be translated either by your medical school or a U.S. translation company.

FCVS: If you are using FCVS to verify your medical education, you do not need to complete the Board’s

Medical Education Verification Form.

Please note: The Board of Registration in Medicine (Board) will not grant a limited license prior to the medical school awarding you an M.D. or D.O. degree. In the event that your medical school has determined that you have not met the requirements for graduation, you must notify the Board within 24 hours following notification by your medical school.

SUPERVISORY EVALUATION FORM

If this is your first postgraduate training program, you do not need to complete the Supervisory Evaluation Form.

If you ever had any postgraduate training in another state, whether or not it was completed, the Supervisory

Evaluation Form must be completed by the program director or the department chairman. If you were practicing medicine or had medical staff privileges, the Supervisory Evaluation Form must be completed by the department chairman, department chief or another person who supervised your clinical activity. The Supervisory Evaluation

Form must be returned to you in a sealed envelope and included with your Initial Limited License Application. If the seal on the envelope is opened, it will be returned to you and then you will have to repeat the process.

Note: Evaluation forms must be current within 120 days prior to Board review. The Board reserves the right to require additional Supervisory Evaluation forms be submitted in connection with your application for licensure.

Initial Limited Lic App (Instructions), Page 12 of 14, Rev. 1/19

MALPRACTICE HISTORY REQUEST FORM

Only for applicants who held a full license in any state or who were named in a medical malpractice claim while in a postgraduate training program. Complete the Malpractice History 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. Include the liability carrier for the time period when you were in a postgraduate training program only if you had a full license OR you were named in a malpractice case during that period.

Send a copy of the malpractice history form to all liability carriers from the date that your first full license was issued, whether or not a claim or suit was filed against you.

Send the signed original Malpractice History Request Form back to the Board along with your limited license application.

If you were enrolled in a postgraduate training program, you do not need to list a liability carrier for the time period when you were in a training program unless you had a full license OR you were named in a malpractice case.

Note: If a malpractice history report is unavailable from the liability carrier due to merger or if the carrier is no longer in business, you must obtain a letter confirming the merger or closure from the liability carrier that took over in the merger or the Division of Insurance in the state where the liability carrier was registered.

STATE LICENSE VERIFICATIONS

You must obtain a written verification of every full license issued to you in the U.S., Puerto Rico or Canada in support of your limited license application. The state boards of California, Texas, Indiana and Pennsylvania will only send license verifications directly to the Massachusetts Board of Registration in Medicine. If the other state medical board provides license verifications through Veridoc, your license verification will be sent electronically to the Massachusetts Board.

Current Probation Agreement in another State: It is the practice of the Licensing Committee, a committee of the Board of Registration in Medicine, to defer action on applications from individuals with a current probation agreement in another state, until that state’s licensing board has terminated the probation.

Initial Limited Lic App (Instructions), Page 13 of 14, Rev. 1/19

**INTERNATIONAL MEDICAL GRADUATES ONLY**

Education Commission for Foreign Medical Graduates (ECFMG) Status Report

An ECFMG Status Report may be requested at https://cvsonline2.ecfmg.org/ImgGenInfo.asp. The ECFMG

Status Report will be sent electronically to the Board. If you are using FCVS, your ECFMG verification will be provided to the Board in your FCVS credentials packet.

Medical School Diploma

International medical school graduates must provide a notarized copy of their medical school diploma with their limited license application. The notarization must be completed by a U.S. notary and, if it is not in English, it must be translated by a U.S. translation company.

J WAIVER FORM – Substantial Equivalency of Medical School Education/Off-Site Clinical Rotations:

If an applicant completed any required/core clinical rotations or more than three (3) months of any elective clinical rotations during medical school outside of the primary teaching hospital of their medical school of attendance, they must submit the following: J Waiver Form and E-1 Form and E-2 Forms. You must send a copy of the E-1 Form to your medical school and the E-2 Forms must be forwarded to the program director at the facility where you completed each clinical clerkship rotation. E-2’s must be sent to the Board in sealed envelopes. Additionally, the applicant must arrange for submission of their postgraduate training evaluative files to support their request for a waiver.

The Board will review the applicant’s medical school training and/or off-site clinical rotations to determine whether they are substantially equivalent to U.S. medical school training. In assessing the applicant’s equivalency of medical education, the Board relies on the factors detailed in Board Policy 91-003 and outlined in the J Waiver Form. If the Board determines that an applicant is not eligible for a waiver of substantial equivalency of medical school education, the Board may preliminarily deny the application for licensure based upon a determination that the applicant does not meet the requirements for licensure set forth in the Board’s statutes and regulations. The Waiver for Substantial Equivalency of Medical School education, Board Policy 91-

003 and the E-1 and E-2 forms are available at the Board’s website. Requesting a waiver for substantial equivalency of medical school education may result in a delay in processing your limited license, as determinations on waiver requests are made by the Board on a case-by-case basis.

Please note: The Board has determined that the medical education at the following medical schools is substantially equivalent to U.S. medical school training. Graduates of the following medical schools do not have to complete the J Waiver Form or Forms E-1 and E-2:

St. George’s University School of Medicine;

SABA University;

Ross University School of Medicine; and

The American University of the Caribbean.

https://cvsonline2.ecfmg.org/ImgGenInfo.asp

Initial Limited Lic App (Instructions), Page 14 of 14, Rev. 1/19

TELEPHONE DIRECTORY AND WEBSITE ADDRESSES

American Medical Association ................................................................................ (800) 621-8335 www.ama-assn.org

American Osteopathic Association…………………………………………….… (888) 626-9262 www.osteopathic.org

Board of Registration in Medicine ........................................................................... (781) 876-8200 www.mass.gov/massmedboard

Education Commission for Foreign Medical Graduates (ECFMG) ......................... (215) 386-5900 www.ecfmg.org

Federal Drug Enforcement Administration (DEA) .................................................. (617) 557-2468 www.deadiversion.usdoj.gov

Federation of State Medical Boards (FSMB) ........................................................... (817) 868-4000 www.fsmb.org

Massachusetts Department of Public Health--Controlled Substance License .......... (617) 973-0949 https://www.mass.gov/orgs/massachusetts-controlled-substances-registration

Massachusetts Medical Society ................................................................................ (781) 893-4610 www.massmed.org

National Board of Medical Examiners (NBME) ...................................................... (215) 590-9500 www.nbme.org

National Board of Osteopathic Medical Examiners (NBOME) ............................... (773) 714-0622 www.nbome.org

National Practitioner Data Bank (NPDB) ................................................................ (800) 767-6732 www.npdb.hrsa.gov http://www.ama-assn.org/ http://www.osteopathic.org/ http://www.mass.gov/massmedboard http://www.ecfmg.org/ http://www.deadiversion.usdoj.gov/ http://www.fsmb.org/ https://www.mass.gov/orgs/massachusetts-controlled-substances-registration http://www.massmed.org/ http://www.nbme.org/ http://www.nbome.org/ http://www.npdb.hrsa.gov/

Initial Limited Lic App – Form 1 (Checklist), Page 1 of 4, Rev. 1/19

INITIAL LIMITED LICENSE APPLICATION CHECKLIST

All documents from primary sources must be received as indicated below. If the document must be submitted in a sealed envelope, the facility seal or signature must be on the back of the envelope. DO NOT OPEN THE ENVELOPES. Please Contact the Program Coordinator at your training program if you have any questions. This checklist should be submitted to the Board with your application.

Applicant’s Name (Print):

(First) (Middle) (Last)

Massachusetts Training Facility:

DESCRIPTION OF DOCUMENTS REQUIRED

TO BE INCLUDED IN YOUR INITIAL SUBMISSION

Applicant

Document

Checklist

For

Board use only

Check for $100.00

Must be from a U.S. bank (or a U.S. money order).

Made payable to the Commonwealth of Massachusetts.

Application cannot be processed without the fee.

Application fee is non-refundable.

Initial Limited license application

All fields completed.

All questions answered.

Timeline of Activities completed if more than 30 days has passed since graduation from medical school.

Application signed and dated.

Provide explanation for “yes” answers and additional documentation in accordance with instructions.

Authorization for Release of Information form

Signed and dated.

Current Curriculum Vitae, if more than one year has passed since your graduation from medical school.

Interview – You will be notified if a personal interview will be required.

Initial Limited Lic App – Form 1 (Checklist), Page 2 of 4, Rev. 1/19

ALL APPLICANTS MUST PROVIDE THE FOLLOWING REQUIRED

DOCUMENTS DIRECTLY FROM PRIMARY SOURCE.

(APPLICANTS MUST NOT OPEN ENVELOPES.)

Applicant

Document

Checklist

For

Board

Medical Education Verification Form (sealed envelope or through FCVS)

USMLE, NBME, AOA, LMCC or FLEX examination scores (from the training program directly through ERAS OR; through FCVS; or electronically from the following websites:

USMLE, FLEX - www.fsmb.org

NBME – www.nbme.org

LMCC (Canada) – www.mcc.ca http://www.fsmb.org/ http://www.nbme.org/ http://www.mcc.ca/

Initial Limited Lic App – Form 1 (Checklist), Page 3 of 4, Rev. 1/19

ALL APPLICANTS MUST PROVIDE THE FOLLOWING

REQUIRED DOCUMENTS FOR ANY “YES” ANSWERS.

(APPLICANTS MUST NOT OPEN ENVELOPES.)

Checklist

For

Board

If you ever held a full license in another state:

State License Verifications from current and past state license boards where you have held a full license (sealed envelopes; electronically from State Board; or Veridoc)

If you ever participated in a postgraduate training program in the United

States:

Supervisory Evaluation Form completed by a supervising physician

(i.e. Program Director)

If you ever held a full license in any state and/or were named in a medical malpractice claim:

Malpractice History Request Form listing ALL liability carriers with dates of coverage and policy numbers.

Malpractice claim report(s) or letter regarding malpractice claim from the attorney or liability carrier(s);

Copy of the complaint or claim letter; and

If claim is closed, a copy of final judgment or other closing papers from the attorney or liability carrier(s).

Attorney or liability carrier(s) should send this information directly to the

Board (sealed envelope).

If you were charged with a criminal offense:

Provide police reports and court reports from the police department or courthouse (sealed envelope).

If you were the subject of discipline or probation during medical school;

were charged with a criminal offense during medical school; had a leave of absence or an extension of medical school; or if you withdrew or transferred from medical school:

Provide the Medical Student Performance Evaluation letter from applicant’s medical school (sealed envelope).

Initial Limited Lic App – Form 1 (Checklist), Page 4 of 4, Rev. 1/19

Checklist

For

Board

International Medical Graduates ONLY:

ECFMG Status Report (sent electronically) www.ecfmg.org

Medical education transcript (An official medical school transcript prepared on university letterhead affixed with the signature of the dean or registrar. The transcript must be mailed directly from the medical school to the Board to be acceptable. If the medical education transcript is not in English, it must be translated by your medical school. If your transcript is in a language other than English, the

Board will send a copy of the transcript to you to be translated by a

U.S. translation company)

Medical school diploma (A notarized (US 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 School Education and Off-Site

Rotations ONLY:

(This applies only to applicants who completed any required or more than three (3) months of elective clinical rotations outside of the primary teaching hospital of their medical school of attendance.)

Waiver Request (Form J) - All fields completed; signed; and dated

E-1 Form (send to medical school)

E-2 Form (send to each program director where you completed a clinical clerkship. E-2 Forms must be returned directly to the applicant in a sealed envelope. DO NOT OPEN THE ENVELOPE.

When all E-2 forms are collected, please forward to the Board).

The Board has determined that the medical education at the following medical schools is substantially equivalent to U.S. medical school training.

Graduates of the following medical 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.

http://www.ecfmg.org/

Application #: ______________________ For Board Use Only

Initial Limited Lic App – Form 2 (Application), Page 1 of 15, Rev. 1/19

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

INITIAL LIMITED LICENSE APPLICATION

Non-refundable Application Fee: A $100.00 check or money order payable to the Commonwealth of

Massachusetts must be included with your limited…