The L For Texas Medical Board form is a crucial document used for the licensure evaluation of physicians in Texas. It verifies postgraduate training and professional history, ensuring that applicants meet the necessary qualifications for medical practice. Those interested in applying should complete the form by clicking the button below.
The L For Texas Medical Board form, officially known as the Physician Licensure Evaluation, serves a critical role in the licensure process for medical professionals in Texas. This comprehensive form requires applicants to provide detailed personal information, including their full name, date of birth, and contact details, as well as the specifics of their postgraduate training and professional history. Applicants must gather evaluations from every facility they have been affiliated with over the past five years, ensuring that their medical competence and professional conduct can be thoroughly assessed. The form also includes sections for evaluating physicians to provide their insights regarding the applicant's training, reliability, and ethical standards. Notably, evaluators must hold specific positions, such as Chief of Staff or Medical Director, and are required to submit the completed form directly to the Texas Medical Board through designated channels. The form emphasizes confidentiality while also outlining the necessary permissions for the release of pertinent information, thereby facilitating a transparent evaluation process. Overall, the L For Texas Medical Board form is an essential document that helps maintain the integrity of medical practice in Texas by ensuring that only qualified individuals receive licensure.
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:
Completing the L For Texas Medical Board form is a crucial step in the licensure evaluation process. This form requires detailed information about your postgraduate training and professional history. Gathering the necessary information ahead of time will streamline the process and help ensure that your application is complete and accurate.
After completing the form, it must be submitted directly to the Texas Medical Board. The evaluating physician can send it by mail, fax, or email, following the specific guidelines provided on the form. Ensure that all sections are filled out accurately to avoid delays in the evaluation process.
What is the purpose of the L For Texas Medical Board form?
The L For Texas Medical Board form, also known as the Physician Licensure Evaluation, is designed to verify a physician's postgraduate training and professional history. This form is essential for applicants seeking licensure in Texas, as it provides the Texas Medical Board with critical information about the applicant's qualifications and conduct in their medical career.
Who needs to fill out this form?
Applicants for medical licensure in Texas must complete this form. Additionally, evaluations must be provided by a physician who holds a specific position, such as Chief of Staff, Department Chairman, Medical Director, or Training Director at the institution where the applicant trained. This ensures that the evaluation comes from a credible source familiar with the applicant's performance.
What information is required from the applicant?
The applicant must provide personal details, including their full name, date of birth, Texas Medical Board ID, and contact information. Furthermore, they need to list all facilities they have been affiliated with over the past five years and specify their position at each institution, such as intern, resident, fellow, faculty, or staff. This comprehensive information helps the board assess the applicant's training and qualifications.
How should the evaluating physician submit the completed form?
The evaluating physician has three options for submitting the completed form. They can send it by mail, fax, or email. If mailing, the form should be placed in a sealed envelope with the physician's signature over the flap. For fax submissions, the form must include an official cover sheet from the hospital or institution. Email submissions must come from an official email address associated with the institution. Submissions from the applicant's email or without proper documentation will not be accepted.
What happens if the applicant has affiliations older than five years?
While the form primarily requires evaluations from the past five years, the licensure analyst may request additional evaluations for affiliations beyond this timeframe. It is important for applicants to be prepared to provide any necessary documentation that could support their application and demonstrate their medical competence.
What is the significance of the confidentiality statement on the form?
The form includes a confidentiality statement that ensures all information provided is kept confidential under the Medical Practice Act. However, if the application is referred to the Licensure Committee for review, the applicant will receive a copy of the form and any attachments. This transparency helps maintain the integrity of the evaluation process while protecting sensitive information.
What should the evaluating physician do if they have concerns about the applicant?
If the evaluating physician has concerns about the applicant's behavior or professional conduct, they should provide detailed explanations in the appropriate sections of the form. This includes any instances of disciplinary action, limitations placed on the applicant, or any unusual circumstances that may have arisen during their training. Such information is vital for the Texas Medical Board to make informed decisions regarding licensure.
How can applicants ensure their form is processed smoothly?
To facilitate a smooth processing of their application, applicants should ensure that all sections of the form are completed accurately and that the evaluating physician submits the form according to the specified guidelines. Keeping lines of communication open with the evaluating physician can also help clarify any questions or concerns that may arise during the evaluation process.
Filling out the L For Texas Medical Board form requires careful attention to detail. One common mistake is failing to provide the applicant's current full name as required. This can lead to confusion and delays in processing the application. Ensure that the name matches official documents to avoid complications.
Another frequent error is not listing all relevant affiliations from the past five years. Applicants often overlook this requirement, thinking only recent positions matter. However, the Texas Medical Board mandates evaluations from every facility affiliated with the applicant during this timeframe, which is crucial for a comprehensive review.
Inaccurate or incomplete dates of affiliation can cause significant issues. Applicants sometimes enter incorrect dates or omit them altogether. This oversight can lead to discrepancies that may raise red flags during the evaluation process. It is essential to double-check these dates for accuracy.
Some applicants neglect to specify their position at the time of affiliation. This detail is important for the evaluators to understand the applicant's role and responsibilities. Without this information, the evaluation may lack context, potentially hindering the assessment.
Additionally, failing to authorize the release of necessary information can stall the application. The form requires a signature to allow hospitals and institutions to share relevant records. If this authorization is missing, the Texas Medical Board may not be able to obtain essential evaluations.
Another mistake involves the evaluator's submission method. The form must be sent directly from the evaluating physician’s official email or by mail with the proper signature on the envelope. Submissions from the applicant's email or without the required coversheet will not be accepted, which could delay the process.
Lastly, applicants often do not provide accurate or complete answers to the verification of professional history questions. Any inconsistencies or lack of detail can raise concerns and lead to further inquiries. It is vital to answer all questions thoroughly and truthfully to ensure a smooth evaluation process.
The L For Texas Medical Board form is a crucial document for physician licensure evaluation. Several other forms and documents are commonly used in conjunction with this application to ensure a comprehensive review of an applicant's qualifications and history. Below is a list of these documents, each serving a specific purpose in the evaluation process.
Each of these documents plays a vital role in the evaluation process for physician licensure in Texas. Together, they help the Texas Medical Board make informed decisions regarding an applicant's ability to practice medicine safely and effectively.
The L For Texas Medical Board form shares similarities with several other documents used in the medical licensure and evaluation process. Below is a list of seven such documents, highlighting their key similarities:
Things You Should Do:
Things You Shouldn't Do:
Here are 10 common misconceptions about the L For Texas Medical Board form, along with clarifications:
Many believe that evaluations from the last year are sufficient. In reality, evaluations from every facility affiliated with the applicant in the past five years are required.
Some think that a simple letter of recommendation will suffice. However, this form must be completed by a designated evaluating physician and cannot be substituted.
It is a misconception that applicants can submit evaluations themselves. Evaluating physicians must send the completed form directly to the Texas Medical Board.
People often assume that only those in training need to fill out this form. In fact, it is necessary for both training and non-training positions, though the requirements differ slightly.
Some individuals believe that the information on the form is public. While it is confidential, applicants can receive a copy if their application goes to the Licensure Committee.
Many think they can skip questions. However, all sections must be completed accurately to ensure a thorough evaluation.
There's a misconception that any physician can complete the evaluation. Only those in specific roles, such as Chief of Staff or Medical Director, are authorized to do so.
Some believe they can simply fax the form. In reality, it must be accompanied by an official coversheet from the evaluating institution.
People may think that any past issues with professionalism or behavior are not significant. However, these factors are critically assessed during the evaluation process.
Lastly, some assume that once the form is submitted, the process is complete. In fact, additional information may be requested by the licensure analyst.
When filling out and using the L For Texas Medical Board form, several critical points must be understood to ensure compliance and facilitate the application process effectively.
Understanding these key takeaways will aid applicants in navigating the complexities of the licensure evaluation process with the Texas Medical Board.