The L For Texas Medical Board form is a crucial document for physician licensure evaluation in Texas. This form verifies postgraduate training and assesses professional history, requiring input from both the applicant and an evaluating physician. Completing this form accurately is essential for a successful application process.
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Things to Do When Filling Out the L For Texas Medical Board Form:
Things Not to Do When Filling Out the L For Texas Medical Board Form:
FORM L
Physician Licensure Evaluation – Texas Medical Board
Verification of Postgraduate Training and Professional Evaluation
APPLICANT:
Complete the information in this box. You must have evaluations from every facility with which you have been affiliated in the past 5 years. Note – your licensure analyst may require additional evaluations outside the past 5 years.
Applicant’s Current Full Name: ____________________Name at time of affiliation if different: _______________________
Printed
Applicant’s Date of Birth: ______________
Applicant TMB ID# _________________
Applicant’s Address: ____________________________Telephone: ________________ E-Mail: ____________________
Name of Evaluating Hospital/Institution _________________________________________________________________
Address of Evaluating Hospital/Institution _______________________________________________________________
Dates of affiliation From (mm/yy) ___________ To (mm/yy) _________
Department of Affiliation_______________________
Your position at the time of affiliation:
Intern Resident Fellow Faculty Staff
I hereby authorize all hospitals, institutions or organizations, my references, personal physicians, employers (past, present and future), business or professional associates (past, present and future) and all governmental agencies (local, state, federal, or foreign) to release to the Texas Medical Board or its successors any information, files or records, including medical records, educational records, and records of psychiatric treatment and treatment for drug and/or alcohol abuse or dependency, requested by the Board in connection with this application, necessary to determine my medical competence, professional conduct, or physical and/or mental ability to safely engage in the practice of medicine. I further authorize the Texas Medical Board or its successors to release to the organizations, individuals, or groups listed above, any information, which is material to this application, or any subsequent licensure.
I authorize the release of the information contained in this evaluation form to the Texas Medical Board.
___________________________________________________
Applicant’s Signature
EVALUATING PHYSICIAN:
•A physician who currently holds one of the following positions must complete this evaluation: Chief of Staff, Department Chairman, Medical Director, or Training Director. Letters of recommendation or standard institution verification forms will not be accepted in lieu of this form.
•This completed evaluation should be sent directly to the Texas Medical Board offices via mail, fax, or email.
By mail - Place this form in an envelope of the hospital/institution that you represent, seal the envelope and place your signature over the outside sealed envelope flap. Send to: Texas Medical Board, MC-240, P.O. Box 2029, Austin, TX 78768-2029
By fax - Evaluator must submit the form along with an official hospital/institution coversheet to 888-790-0621. Fax submitted by the applicant and/or without the appropriate coversheet cannot be accepted.
By email - Evaluator must submit the form from an official hospital/institution email address to screen-cic@tmb.state.tx.us. Emails sent from the applicant or from a non-agency email address cannot be accepted.
Title:
Chief of Staff
Evaluating Physician’s
Department Chairman
Medical Director
Name/Degree:
Training Director
Phone:Address:
Fax:E-Mail:
Evaluating Physician's License Number and
State of Licensure
LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION
Version 01.2020
Applicant's Name___________________________________________
Page 2
This is important: All information on this Form L, (including attachments that you provide as the Evaluating Physician) regarding a licensure applicant is confidential pursuant to §164.007(c) of the Medical Practice Act. However, the Board must provide a copy of this Form L and attachments to an applicant when an application is referred to the Licensure Committee for licensure determination. Any information furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity from Civil Liability.
FOR TRAINING POSITIONS – Completion of the Verification of Post Graduate Training and the Verification of Professional History sections are required.
FOR NON-TRAINING POSITIONS – Only completion of the Verification of Professional History section is required.
VERIFICATION OF POST GRADUATE TRAINING
This section relates to postgraduate training. If this individual did not complete postgraduate training at this institution please skip to the Verification of Professional History section.
Department:
PROGRAM PARTICIPATION: (For
PGY: _______
___________________________________
training positions only)
___ Internship
From: ___/___/___
To: ___/___/___
Report incomplete postgraduate years
___ Residency
Credit received?
___ Fellowship
(PGY) separately from those that were
___ Research
Full
*Partial
in progress
successfully completed.
If the postgraduate year is currently in
*For partial credit– how many months?______
progress, report the expected completion
date in the “To” field.
Report Internships, Residencies and
Fellowships separately. Use one section
per department.
UNUSUAL
Yes No
1.
Did this individual ever take a leave of absence or break from training?
CIRCUMSTANCES:
2.
Did this individual resign from training?
(For training
3.
Were any limitations or special requirements placed upon this individual for
positions only)
professionalism or behavioral issues?
Please attach an
4.
Did this individual ever receive a written warning or documented counseling
about his/her behavior?
explanation for any
5.
Was this individual ever placed on probation for any reason?
“yes” response.
6.
Is this individual currently under investigation?
7.
Were this individual’s privileges or duties ever reduced, suspended, or
revoked?
8.
Did this individual experience delayed promotion or delayed advancement to
the next level?
9.
Was this individual informed his/her contract would not be renewed?
10. Was this individual suspended, terminated, or dismissed from training?
Page 3
VERIFICATION OF PROFESSIONAL HISTORY
This evaluation is based on Personal Knowledge
Review of Credential File
How long have you known the applicant? Years________ Months ________
Is the applicant related to you?
Yes
No
Do you know the applicant well?
Has your acquaintance with the applicant continued until recent date?
6.Do you consider the applicant:
(a) Reliable?
(b) Ethical?
(c) Of good character?
7.Please rate the applicant:
Excellent
Good
Average
Poor
(a)Professional ability
(b)Attention to duties
(c)Breadth of education
(d)Interpersonal skills
8.Has applicant, to your knowledge, ever been guilty of:
(a) Fraud or dishonesty?
(b) Unprofessional conduct?
9.To your knowledge, has the applicant ever:
(a) been warned, censured, reprimanded, disciplined, had admissions monitored or privileges limited
or suspended?
(b) had disciplinary action taken against him/her by a licensing agency?
(c) been denied or surrendered a federal or state controlled substance permit?
(d) been arrested, fined, charged with or convicted of a crime, indicted, imprisoned
or placed on probation?
(e) been a defendant in a legal action involving professional liability (malpractice) or had a
professional liability claim paid in his/her behalf or paid such a claim him/herself?
(f) been placed on probation, asked to withdraw, or reprimanded?
(g) been terminated, resigned in lieu of termination or during investigation?
If you answered "yes" to any of the above questions, please provide any additional information you may have, including the names of other individuals who may have information concerning this applicant.
10. Are the dates of privileges provided by the applicant on the top portion of this form accurate?
11.If not, please provide the correct dates: Beginning month _____ / year ____Ending month _____ / year _______
Evaluating Physicians Name:
Signature
Date:
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The L Form for the Texas Medical Board is a critical document for physicians seeking licensure in Texas. It requires comprehensive evaluations from institutions where the applicant has trained or worked. Along with this form, several other documents are often necessary to ensure a complete application. Below is a list of forms that may be required in conjunction with the L Form.
Each of these documents plays a vital role in the licensure process, ensuring that the Texas Medical Board has a complete picture of the applicant's qualifications and history. Submitting all required forms accurately and promptly can significantly impact the speed and success of the licensure application.
Filling out the L For Texas Medical Board form can be straightforward, but many applicants make common mistakes that can delay the process. One frequent error is failing to include all required evaluations from every facility affiliated with the applicant in the past five years. This oversight can lead to unnecessary complications and requests for additional documentation.
Another mistake involves incorrect or incomplete personal information. Applicants sometimes forget to provide their full name as it appears on official documents or neglect to fill in their Texas Medical Board ID number. This information is crucial for identification and processing.
Many applicants also overlook the importance of signing the form. Without a signature, the application is considered incomplete, and the Texas Medical Board cannot proceed with the evaluation. It is essential to ensure that all required signatures are present before submission.
Inaccuracies in the dates of affiliation can cause problems as well. Applicants may mistakenly report the wrong months or years, which can lead to confusion during the verification process. Double-checking these dates is vital for a smooth evaluation.
Some applicants fail to specify their position at the time of affiliation. This section is important as it helps the evaluators understand the applicant's role and responsibilities during their training. Omitting this detail can result in delays or requests for clarification.
Additionally, applicants sometimes neglect to answer the questions regarding unusual circumstances during their training. If there were any issues, such as leaves of absence or disciplinary actions, these should be disclosed. Not providing this information can raise red flags later in the evaluation process.
Another common error is submitting the form without the necessary attachments or additional documentation. If the evaluating physician is required to provide extra information, failing to include it can hinder the application’s progress. Always ensure that all required documents accompany the form.
Finally, sending the completed form to the wrong address or using an incorrect method of submission can lead to significant delays. Applicants should carefully follow the submission guidelines provided to ensure their evaluation reaches the Texas Medical Board promptly.
In reality, evaluations are required from every facility with which the applicant has been affiliated in the past five years. This ensures a comprehensive assessment of the applicant's training and professional history.
This is not true. The evaluation must be completed by a physician holding specific positions, such as Chief of Staff or Medical Director. Standard letters of recommendation are not acceptable.
The completed evaluation must be sent directly from the evaluating physician to the Texas Medical Board. Submissions made by the applicant will not be accepted.
While the information is confidential, it may be shared with the applicant if their application is referred to the Licensure Committee. This transparency is part of the evaluation process.
The form is required for both training and non-training positions, but the sections to be completed differ. Non-training positions require only the Verification of Professional History section.
The evaluator is expected to have a good understanding of the applicant's professional abilities and character. This knowledge is crucial for providing an accurate evaluation.
While the form may seem simple, the process can take time. Evaluators must carefully consider each question and provide detailed information, especially if any issues arise during the applicant's training.
Evaluators are encouraged to provide thorough answers, especially if any "yes" responses are given to the questions regarding the applicant's conduct or history. Additional explanations are often necessary.
The Board considers various documents and information when reviewing an application. The evaluation is just one part of a larger picture that includes other records and assessments.
Filling out the L For Texas Medical Board form is a crucial step in the physician licensure process. Here are some key takeaways to ensure you navigate this process smoothly:
By keeping these key points in mind, you can approach the L For Texas Medical Board form with confidence, knowing that you are taking the necessary steps toward your medical licensure.
Completing the L For Texas Medical Board form is a crucial step in the licensure process. Ensure that all required sections are filled out accurately and completely. Missing information may delay your application. Follow these steps carefully to avoid any issues.