INITIAL LIMITED LICENSE APPLICATION

Transcription

1 Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: INITIAL LIMITED LICENSE APPLICATION PLEASE NOTE: As the applicant, you are responsible for the accuracy of this licensing information. If you have questions concerning the licensing process, contact the residency program coordinator or the residency training office at the Massachusetts hospital where your training will be undertaken. LIMITED LICENSE FEE: The fee for a limited license is $ Please attach a personal check or money order payable to the Commonwealth of Massachusetts. Applications will not be processed without the fee. IMPORTANT INFORMATION: Limited licenses are issued to physicians enrolled in postgraduate medical education programs in health care facilities in the Commonwealth of Massachusetts. All such training must be done in ACGME-accredited programs, or in a subspecialty clinical training or fellowship program in a training facility that has an approved program in the parent specialty. This information must be documented by the training program in Section B of this Limited License Application. You may practice medicine only in the training program approved with this application. With a limited license you are not allowed to moonlight under any circumstances. A physician who holds or who has ever held a full Massachusetts license is not eligible for a limited license. Processing time for an Initial Limited License Application is approximately six (6) to eight (8) weeks after licensing materials from all sources have been received by the Board of Registration in Medicine. Some applications may require a longer processing time. The Board will notify the training program upon approval of your limited license. You may not engage in direct or indirect patient care until your license has been approved. Following Board approval of your limited license, your limited registration certificate verifying your registration number will be sent to your training program and they will provide you with a copy of the certificate. 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. Initial Limited License Instructions Page 1 of 11

2 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 sent to the Board at least 30 days prior to the end of the academic year. The Board may issue a limited license up to a maximum of 5 licenses. A request for a limited license beyond the maximum of 5 licenses may be granted only in extraordinary circumstances and is subject to review by the Board. The Limited License Application Kit includes: Initial Limited License Application Form, comprised of Sections A, B and C (and supplemental pages if you answer yes to any of the questions on Sections A and C). Medical Education Verification form for premedical and medical education Request for Status Report of ECFMG Certification (International Graduates) State License Verification(s) from all states where you have ever held a full license Evaluation form Authorization for Release of Information form must be completed and included with your application In addition to these required forms, please provide the Board with an updated curriculum vitae (by month and year). Initial Limited License Instructions Page 2 of 11

3 INSTRUCTIONS FOR COMPLETING LIMITED LICENSE FORMS Initial Limited License Application Form: Complete Sections A and C, as well as any other forms that apply. After completion of Sections A and C, forward the application to the training program for completion of Section B. Medical Education Verification Form: Pre-medical education must be certified by your medical school(s) on the Medical Education Verification form. You must have successfully completed two (2) years of at least thirty-two (32) weeks in each year of pre-medical education. If you attended more than one medical school you must obtain verification from all schools. Do not open the envelope from your medical school and inform the members of your household not to open the envelope. If the seal on the envelope from your medical school is broken, the Medical School Verification form will not be accepted and you will be required to obtain a new Medical School Verification. This will delay the processing of your limited license application. 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. The Medical School Status Update form is available on the Board s website at massmedboard.org., select Physician Information, and Downloadable Forms. Failure to notify the Board within the specified time frame could preclude you from obtaining future licenses in Massachusetts. International Medical Graduates - Send your Medical Education Verification form via an international carrier with a prepaid return envelope addressed to you so that the medical school can send it directly to you. If the medical school verification and transcripts are provided in a language other than English, you must provide an official translation by a translation company in the United States. You must send a notarized copy of your medical school diploma with your limited license application. If your diploma is not written in English, you must also provide an official translation by a translation company in the United States. Transfers: If you have transferred from one medical school to another, please request a letter from medical school office explaining the reason(s) for the transfer. The letter should be sent to you and included with the limited license application. If the seal on the envelope is broken, you will be required to obtain a new letter and your limited license application will be delayed. Initial Limited License Instructions Page 3 of 11

4 Authorization for Release of Information: The Authorization for Release of Information form must be signed and returned with your limited license application. State License Verification: If you are currently licensed, or if you have ever been fully licensed anywhere in the United States, Puerto Rico, or Canada, you must authorize verification of your licensure to the Board of Registration in Medicine. Please sign the State License Verification form and send it to the appropriate state medical licensing board. Request the state licensing board to send the verification of your state license to you and include it with your limited license application. If the seal on the envelope from the state board is broken, the state license verification will not be accepted by the Massachusetts Board. The envelope and its contents will be returned to you and then the process must be repeated. Evaluation Form: The Evaluation Form must be completed by your most recent training program director. If you had previously completed training in another state and were practicing medicine, the Evaluation Form must be completed by the program director or the department chairman where you had active medical staff privileges. If this is your first postgraduate training program, you do not need to complete this form. The Evaluation Form must be sent to you in a sealed envelope from the program director or the department chairman and include it with your limited license application. If the seal on the envelope is broken, it will be returned to you and then you will have to repeat the process. International Medical Graduates ECFMG Status Report: The ECFMG Status Report must be sent directly to the Board from ECFMG electronically. Go to for information and instructions on how to apply for your ECFMG status report to be sent to the Board. Please note that FMGEMS is not an accepted qualifying examination. Qualifying Examinations: International medical graduates must have passing scores on USMLE Steps 1 and 2, NBME Part I and II, both Components 1 and 2 of the FLEX, or a combination of these examinations. Substantial Equivalency of Medical School Education: In situations where an international medical graduate cannot comply with 243 CMR 2.03(1) (b), requiring substantial equivalency of medical school education, a Waiver Request may be submitted to the Board. If an applicant completed more than three (3) months of elective clinical training, or any required clinical training of the (2) two-year clinical study requirement was not completed on the site of your medical school, you must send a copy of Form E-1 to your medical school. Form E-2 must be forwarded to the program director at the program where you completed each clinical experience. This form must be returned directly to the Board of Registration in Medicine. Forms E-1 and E-2 apply only to applicants whose clinical training was done away from the site of their school. The Waiver Request and Forms E-1 and E-2 are available in the medical education office at the program training site. Initial Limited License Instructions Page 4 of 11

5 Fifth Pathway Graduates: Graduates of Fifth Pathway programs must also submit a notarized copy of a certificate of completion of a year of clinical training at an approved medical school in the United States or Canada. DEFINITIONS: IMG. - International Medical School Graduates. Graduates of medical schools legally chartered in a sovereign state other than the United States or Canada. Fifth Pathway - means a program of medical education which meets the following requirements: 1) Completion of two (2) years of premedical education in a college or university of the United States; 2) Completion of all the formal requirements for the degree corresponding to doctor of medicine, except internship and social service in a medical school outside the United States which is recognized by the World Health Organization; 3) Completion of one (1) academic year of supervised clinical training sponsored by an ACGME approved teaching hospital in the United States or Canada. ECFMG: Educational Commission for Foreign Medical Graduates. ACGME: Accreditation Council for Graduate Medical Education. Attendance: During the first two (2) years of medical school is defined as physical presence at the program for matriculation. Attendance during the third and fourth years of medical school is defined as enrollment in clinical study at the degree granting institution and as further described by the Board of Registration in Medicine s regulations under Medical School Education Verification form above. Translations: Original translations must be provided for any documents in a language other than English. If such transcript is provided in a language other than English, you will be asked by the Board of Registration in Medicine to provide an official translation by a translation company in the United States. English translations received by the Board of Registration in Medicine directly from the Medical School Dean will be accepted. If you wish to have original U. S. translations returned, you must enclose a notarized copy of the translation and a self-addressed stamped envelope with sufficient postage affixed. The Board of Registration in Medicine will keep your notarized copy and return the original to you. An Official U. S. Translation Company is a private organization located in the United States engaged solely in the practice of translating documents and inter-language communication, e.g. Berlitz, Polylingua, Inc., etc. These companies can be located by looking under Translators and Interpreters in the Yellow Pages of the telephone book. An office of a U.S. translation company located outside the United States is acceptable. Important Note: Following the submission of your application for licensure, the Board may at any time request additional documentation to determine the applicant s Initial Limited License Instructions Page 5 of 11

6 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. SECTION A APPLICATION INSTRUCTIONS 1-B. Other name(s): If you have had a name change, 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 Name Change form. 2. Current residence: Provide a mailing address and telephone number at which we can reach you. You must immediately notify the Board of any change in this information. 5. 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. 6. Name and address of Massachusetts training hospital: This is the name of the program at which you will be practicing with your Limited License. This information should correspond with the information in Section B. 7. Name of premedical school(s): Supply the name of the school(s) at which you completed your undergraduate premedical education. 11. Examinations completed: Indicate all licensing examinations which you have completed with a passing score. 12 A or B: Completion of medical school education: If you answered yes to question #12-A or 12-B, please supply an explanation on a separate piece of paper. U.S medical graduates must explain the reason(s) for more than 4 years of medical school training. International medical graduates must explain the reason(s) for more than 6 years of medical school training. 13. Time between graduation and start of training: If you answered yes to this question, attach a detailed list of your activities, both professional and non-professional, and the dates in which you engaged in each of these activities, arranged in chronological order up to the present time. Be sure to include all employment experiences and training programs. SECTION B MUST BE COMPLETED BY THE TRAINING PROGRAM Initial Limited License Instructions Page 6 of 11

7 SECTION C The following instructions will help you answer Questions If you answer yes to any of these questions, you must also fill out the supplemental pages. Read these instructions and the supplemental pages carefully. Your application may be delayed if you fail to provide all the information requested. This portion of the application is not a public record, and is held as confidential information unless you expressly authorize the Board to release it to a particular party. Under the law, the Board may also share this information with legally designated agencies, such as other state licensing boards and law enforcement agencies. Designated agencies are required to maintain the confidentiality of this information consistent with the law. 15, 20, and 21. Disciplinary Action: A confidentiality agreement does not absolve you of your requirement to answer Questions 15, 20 and 21. If you answer Yes you must also complete the supplement. For the purpose of answering Questions 15, 20 and 21, the terms listed below have the following meanings: An investigation is any inquiry conducted by a private or governmental authority concerning you. This question includes, but is not limited to, investigations, reviews, and inquiries conducted by: hospitals, clinics, nursing homes, health insurers, medical malpractice insurers, professional associations, federal agencies, and state agencies. This question includes investigations, reviews, and inquiries conducted by the Massachusetts Board of Registration in Medicine and its sub-committees, including the Data Repository Committee and the Complaint Committee. You do not need to report investigations of an entire facility or department. For example, an annual departmental review of complication rates is not a reportable investigation within the meaning of this question because your activities have not been singled out for review. A governmental authority refers to any federal, state, county, or municipal governmental entity, including but not limited to: any medical licensing board (including Massachusetts), any agency regulating health care quality, any medical assistance authority, any regulatory authority investigating insurance fraud, and any agency that regulates the possession, dispensing, and prescribing of any controlled substances. A health care facility refers to any hospital (including federal, state, county, and municipal hospitals), clinic, prison infirmary, home for unwed mothers, nursing home, or health maintenance organization. For the purpose of this question, a health care facility includes a post-graduate training program. Initial Limited License Instructions Page 7 of 11

8 Group practice refers to any association of healthcare professionals organized for the delivery of patient care of which you are a member or partner or by which you are employed or with which you have a contract for professional services, including a partnership or limited liability partnership, limited liability company, professional corporation, or other professional business organization. Disciplinary action, as defined in the Board s regulations, is an action which adversely affects a licensee. The action can be formal or informal, oral or written, and voluntary or involuntary. Disciplinary actions that are always reportable to the Board include, but are not limited to, the following or their substantial equivalents: revocation of a right or privilege, suspension of a right or privilege, censure, written reprimand or admonition, fines, and required performance of public service. Disciplinary actions that are sometimes reportable to the Board include, but are not limited to, the following or their substantial equivalents: restriction of a right or privilege, non-renewal of a right or privilege, denial of a right or privilege, resignation, leave of absence, withdrawal of an application, and termination or non-renewal of a contract. These actions are reportable to the Board if they arose, directly or indirectly, from the licensee s competence to practice medicine, or from a complaint or allegation regarding any violation of law, regulation, or bylaw. For example, non-renewal of a medical license in another state based on the licensee s cessation of practice there is not a disciplinary action. For example, a leave of absence taken for family reasons or for illness is not a disciplinary action. For example, termination or non-renewal of an employment contract due to relocation is not a disciplinary action. A course of education, training, counseling or monitoring is reportable to the Board as a disciplinary action only if it arose out of the filing of a complaint or other formal charges reflecting on the licensee s competence to practice. 16-A and 16-B. Transfer, leave of absence, withdrawal or termination from medical school or any postgraduate training program: If you answered yes to 16-A or 16-B, you must complete the supplement form detailing your reasons for non-completion, transfer, withdrawal or change of the program(s). In addition, you must request a letter from the dean of the medical school or the Program Director at the postgraduate training program explaining the reason(s) for the transfer, leave of absence, withdrawal, termination or noncompletion of any medical school or postgraduate training and the circumstances under which you left the program. This letter must be sent directly to the Board by the dean of the medical school or the program director. If you completed a portion of a training program as a prerequisite for entering into a different training program immediately thereafter, you may answer no to this question. Initial Limited License Instructions Page 8 of 11

9 16-C. Probation in medical school or any postgraduate training program: You must report a probation in medical school or any postgraduate training program, regardless of the reason for the probation. 18. Medical license application withdrawal or denial of medical license: You should answer "yes" if you withdrew your application after learning that your license application probably would not be approved or would be approved only with conditions or restrictions. You do not need to answer yes if you withdrew your application solely because of a decision to relocate that was entirely unrelated to anticipated rejection of your application, or if you let your license lapse because you no longer practice medicine in that jurisdiction. 19. Voluntary surrender of license: You must report any surrender of a license to a licensing board or other governmental agency. You do not need to answer yes to this question if you let your license lapse because you no longer practice medicine in that jurisdiction. 20 and 21. See 15 above. 22, 23, 24 and 25. Medical staff membership, status and privileges: You must answer these questions about your medical staff status at any health care facility at which you have ever had membership or privileges. You do not need to include information about your tenure at health care facilities as a medical student or resident. 26. Criminal proceedings: Being charged with a criminal offense includes being arrested, arraigned or indicted, even if the charges against you were dropped, filed, dismissed or otherwise discharged. You must also report: convictions for felonies and misdemeanors; nolo contendere pleas; matters where sufficient facts of guilt were found; matters that were continued without a finding; and any other plea bargain. A medical malpractice claim is a civil, not a criminal, matter. A charge of Driving Under the Influence is not a minor traffic offense and should be reported. 27. Controlled substances privileges: You do not need to answer "yes" if you permitted your state and/or federal license(s) to expire solely because you decided to relocate and your decision to relocate was entirely unrelated to allegations of wrongful or otherwise irregular prescription practices. 28. Malpractice claims: You must report all malpractice claims, whether or not they resulted in lawsuits and whether they are pending or have been resolved. You must answer yes even if you were named in a case or claim and subsequently dropped from it or the case or claim was dismissed with no finding against you or payment made on your behalf. You must report all cases or claims filed or heard in any state. 29. Non-malpractice lawsuits: You must report certain lawsuits filed against you even if they do not allege malpractice. Examples include, but are not limited to lawsuits filed under consumer protection, antitrust, civil rights, fraud, or intentional tort (e.g. libel, interference with contractual relations) laws. You must report only those suits relating to your competency to practice medicine or your professional conduct in the practice of medicine. Initial Limited License Instructions Page 9 of 11

10 30 and 31. Medical condition: Medical condition includes physiological and psychological conditions or disorders including, but not limited to orthopedic, sensory, cognitive, neuromuscular, neurological, psychiatric, infectious, cardiovascular and metabolic conditions and disorders. Medical condition includes learning disabilities and chemical dependency. Ability to practice medicine includes the following: 1. The cognitive capacity to make appropriate clinical diagnoses, exercise reasoned medical judgments, and to learn and keep abreast of medical developments; and 2. The ability to communicate those judgments and medical information to patients and other health care providers, with or without the use of aids or devices such as voice amplifiers; and 3. The physical capability to perform medical tasks such as physical examination and surgical procedures, with or without the use of aids or devices. 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. 32. Use of Chemical Substances: Chemical substances is to be construed to include alcohol, drugs or medications, including those drugs or medications (controlled substances) taken pursuant to a valid prescription for legitimate medical purposes and in accordance with this direction, as well as those used illegally. Illegal use of controlled substances includes use of substances obtained illegally (for example, heroin or cocaine) as well as the use of substances in an illegal manner (for example, use of prescription drugs which are obtained without a valid prescription or taken not in accordance with the directions of a licensed health care practitioner). 34. Illegal use of drugs: See definitions above. You have a right to elect not to answer the above question if you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert the Fifth Amendment privilege against self-incrimination. Any claim of the Fifth Amendment privilege must be made in good faith. If you choose to assert the Fifth Amendment privilege, you must do so in writing. Your limited license application will be processed if you claim the privilege. 35. Voluntary modification of scope of practice: Describe any voluntary modification of or limitation to your scope of practice not covered by Questions 30 and 31, and the reasons for it. A Note to the Physician who is Chemically Dependent If you are chemically dependent, the Board encourages you to seek assistance voluntarily. When the Board receives notice of impairment or dependency, its policy is to protect the public but also to ensure rehabilitation through the physician's participation in Initial Limited License Instructions Page 10 of 11

11 approved treatment programs and supervised, structured aftercare. The Board's Chemically Dependent Physician Policy relies on cooperation between the Board and groups like the Massachusetts Medical Society's Physician Health Services to ensure successful rehabilitation. PLEASE NOTE: If you answered yes to any of Questions 15-35, you must also fill out the supplemental pages. s/share/limited/instructions Initial Limited License Instructions Page 11 of 11

12 CHECKLIST FOR LIMITED LICENSE APPLICATION Before submitting your limited license application to your training program, please refer to this checklist to ensure that you have provided all required documentation and answered all questions. If you do not answer every question, your limited license application will be returned to you and your license will be delayed. HAVE YOU Downloaded all of the pages of the application? Read the instructions, answered every question, signed the application and Authorization for Release of Information and attached a check for $ made payable to the Commonwealth of Massachusetts? Provided an explanation if you attended medical school for more than 4 years for US graduates and 6 years for IMGs? Included a current curriculum vitae listing the months and years of your education, training and clinical activity. Include any gaps or leaves of absence in your training or clinical activity in a separate letter and attach the letter to your curriculum vitae. Included a letter from the director of your most recent postgraduate training program if you did not complete a training program? The letter must be in the original sealed envelope from your program director, unopened and attached to your limited license application. Included the Verification of Medical School education form received directly from your medical school? The Medical Education Verification form must be sent directly to you from the medical school. Do not open the envelope. If the seal on the envelope from your medical school is broken, the Medical Education Verification form will be returned to you and then the process must be repeated. Included license verifications in their original sealed envelopes from every state in the U.S., Canada or Puerto Rico where you ever held a full license? Have you attached them to your limited license application? Included a completed Evaluation form from your most recent training program director or current hospital affiliation if you are not in a training program (see Instructions). A completed Evaluation form is required if you had a malpractice action filed against you (even if you were dismissed from the case) or if you were ever placed on probation or received negative reports in your training program. Instruct the program director to return the Evaluation form to you in a sealed envelope and it should be attached to your limited license application, (For IMGs only). Enclosed a notarized copy of your medical school diploma and Education Commission for Foreign Medical Graduates (ECFMG) certificate. You are also required to provide an ECFMG Status Report. There is a fee for requesting the status report. The ECFMG Status Report must be sent directly to the Board from ECFMG electronically. Go to for information and instructions on how to apply for your ECFMG status report to be sent to the Board. If you completed FLEX Part I and Part II, you must request verification from the Federation of State Medical Boards at or if you completed the National Board Examination (NBME) Part I and Part II, you must request verification from the National Board's web site at Follow the instructions for requesting verification of exam scores to be sent to the Massachusetts Board. IF THE SEALS ON ANY ENVELOPES ARE BROKEN, THE DOCUMENTS WILL NOT BE ACCEPTED BY THE BOARD. PLEASE CONTACT THE PROGRAM COORDINATOR AT YOUR TRAINING PROGRAM IF YOU HAVE ANY QUESTIONS.

13 Application #: Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: INITIAL LIMITED LICENSE APPLICATION IMPORTANT: Read the accompanying instructions before completing this form, and print legibly or type your answers. Please attach a $ check payable to the Commonwealth of Massachusetts. CHECK ONE: Graduate of a Medical School in the United States, Canada, or Puerto Rico (USMG) Graduate of an International Medical School (IMG) NOTE: GRADUATES OF INTERNATIONAL MEDICAL SCHOOLS MUST COMPLETE ADDITIONAL FORMS SECTION A: Sworn Statement To Be Completed by Applicant 1-A. Name: (Last) (First) (MI) 1-B. Other Name(s): 1) Have you ever been known under a different name or combination of names? 2) Have you ever been licensed under a different name? 3) Have you ever applied for licensure, or applied to sit for an examination, or taken an examination under a different name? If you answer yes, you must provide additional information. (See instructions.) YES NO 2. Current Address: Telephone Number: City: State: Zip: 3. Date of Birth: / / Place of Birth: Month Day Year Address 4. Sex: Male Female 5. Social Security Number: Name of Massachusetts Training Program: Street Address (City)

14 Page 2 of 6 PRINT NAME 7. Name of premedical school(s): Location: 8. Name of medical school(s): Location: (City, State, Country) (City, State, Country) Date of Graduation: / / Degree: M. D. D. O. Other (specify) (Month) (Day) (Year) (See Limited Instructions, (page 3), for completing Medical Education forms for fourth year medical school students.) 9. Have you had previous postgraduate training in the United States? No Yes Name of Postgraduate Training Program City: State: Training Dates: From: / / To: / / Specialty: Name of Postgraduate Training Program City: State: Training Dates: From: / / To: / / Specialty: (If additional space is needed, please continue your answer on a separate sheet of paper.) 10. List states (abbreviations) where you ever had a license to practice medicine (include residency training licenses). (Full) (Full) (Full ) (Limited) (Limited) 11. Please indicate all the licensing examinations that you have have completed with a passing score: USMLE Step 1 Step 2 (CK) Step 2 (CS) Step 3 NBME Part 1 Part II Part III COMLEX Level 1 Level 2 LMCC 12-A. If you are a USMG, have you taken more than 4 years to complete medical school? 12-B. If you are an IMG, have you taken more than 6 years to complete medical school? If yes, you must provide additional information. (See instructions). 13. Has more than one year passed between the date of your graduation from medical school and the anticipated start date of your limited licensure in Massachusetts? If yes, you must provide additional information with your curriculum vitae and include the months and dates of any gaps in your professional activities since graduation from medical school. (See instructions.) YES NO

15 Page 3 of 6 SECTION B: TO BE COMPLETED AND SIGNED BY THE DESIGNATED OFFICIAL OF THE TEACHING PROGRAM AT WHICH THE APPLICANT HAS RECEIVED AN APPOINTMENT This certifies that (Name of Applicant) has been appointed to the position of Intern Resident Fellow in the specialty of as a PGY Department: Subspeciality: at (Name of Healthcare Facility) beginning / / to anticipated completion of training: / /. (Month) (Day) (Year) (Month) (Day) (Year) 1. Is the program accredited by the ACGME? 2. If no, is there an ACGME-approved training program in the applicant s specialty? 3. Have you reviewed Sections A and C of the limited license application? Designated Official s Signature: Type or Print Name: Official Title: Date: / / Telephone Number: YES NO SECTION C: PAGES 4-6 MUST BE COMPLETED BY APPLICANT

16 PRINT NAME: Page 4 of 6 SECTION C: Read the instructions. Check either YES or NO to each question. Do not answer N/A. If you answer YES to any of these questions, you must provide details on the Limited License Supplement. You must answer all questions or your application will be returned to you. 14. Have you ever been enrolled in a postgraduate training program where you were required to repeat a year of training? If you answered yes to question 14, you must provide an explanation and a letter from the program director is required. 15. Since your enrollment in college, have you been subject to any disciplinary action (see definition) at any academic institution? 16-A. Have you ever been terminated or granted a leave of absence, regardless of the reason, by a medical school or any postgraduate training program? 16-B. Have you ever voluntarily left, transferred or withdrawn from a medical school or any postgraduate training program? 16-C. Have you ever, for any reason, been placed on probation in medical school or any postgraduate training program? If you answered yes to 16-A, B or C, you must provide an explanation and request a letter of explanation from your medical school or postgraduate training program. 17. Since your enrollment in college, have you been denied the privilege of taking or finishing an examination or have you been accused of cheating and/or improper conduct during an examination? 18. Have you ever, for any reason, been denied a medical license, whether full, limited or temporary, or have you withdrawn an application for medical licensure? 19. Have you ever voluntarily surrendered a license to practice medicine or any healing art? YES NO

17 PRINT NAME: Page 5 of Are any formal disciplinary charges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, health care facility, group practice or professional medical society or association (international, national, state or local)? (See definition). 21. Has any disciplinary action ever been taken against you for violation of laws, rules, by-laws or standards of practice by any governmental authority, health care facility, group practice, or professional medical society or association (international, national, state or local)? (See definition). 22. Have you ever been denied medical staff membership, or advancement in medical staff status, or has such denial been recommended by a standing medical staff committee or governing body? 23. Have you ever, for any reason, withdrawn an application for hospital privileges or appointment? 24. Have you ever voluntarily relinquished any medical staff membership, medical staff privileges or medical staff status? 25. Has your medical staff membership, medical privileges or medical staff status at any hospital 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 or governing board? 26. Have you ever been charged with any criminal offense, other than a minor traffic offense? 27. Has your privilege to 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? 28. In the past ten (10) years, has any medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim or has such a suit been settled, adjudicated or otherwise resolved? 29. In the past ten (10) years, has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against you or has such a suit been settled, adjudicated or otherwise resolved? Revised: YES NO

18 PRINT NAME: Page 6 of 6 CONFIDENTIAL MEDICAL INFORMATION Before completing the following questions, refer to the instructions for definitions and additional information. If answering yes to any of the questions, you must provide details on the Limited License Supplement. 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. YES NO 30. Since becoming a medical student, have you been diagnosed with or treated for a medical condition which in any way currently limits or impairs your ability to practice medicine or function as a physician? 31. Do you currently have a medical condition which in any way limits or impairs your ability to practice medicine or to function as a physician? 32. Within the past two years, have you engaged in the use of chemical substances with the result that your ability to practice medicine is currently limited or impaired? 33. Have you ever refused to submit to a test to determine whether you had consumed and/or were under the influence of chemical substances? 34. Are you currently engaged in the illegal use of drugs or misuse of prescription drugs? 35. Within the past five years, have you voluntarily modified or otherwise limited your scope of practice of medicine for any reason other than a medical condition? If your responses to Questions change while your application is pending, you must notify the Board of the new information immediately. Please note that your license expires at the end of the academic year and must be renewed. A limited licensee may practice medicine only at the institution or its affiliates. With a limited license you are not allowed to moonlight under any circumstances. CERTIFICATIONS: 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 and that I have complied with all laws of the Commonwealth related to withholding and remitting child support. (Note: This applies even if you reside out of the state or out of the country.) Pursuant to G.L. c. 112, 1A, I will fulfill my obligation to report abuse or neglect of children as required by G.L. c. 119, 51A. I will read the Board s regulations, 243 C.M.R through To the best of my knowledge, I meet the qualifications for limited licensure in Massachusetts. Under the penalties of perjury, I declare that I have examined this limited license application and all its accompanying instructions, forms and statements, and to the best of my knowledge, and belief, the information contained herein is true, correct and complete. As an applicant for a limited license to practice medicine, I understand that a criminal record check may be conducted for conviction and pending criminal case information from the Criminal History Systems Board only and that it will not necessarily disqualify me from licensure. Applicant s Signature: Date: / / Revised:

19 PRINT NAME: Page 1 QUESTIONS #15, 20 & 21 Disciplinary actions Attach additional pages with same format where more than one action was taken or is pending, and where otherwise necessary. Name of agency or institution taking action: Date: / /_ Description: You must arrange for the appropriate agency or institution to submit copies of all official documentation and correspondence related to the disciplinary action directly to the Board. QUESTIONS #14, 16-A, 16-B, 16-C &17 Medical school and postgraduate training program Attach additional pages with same format where necessary. Name of institution: _Date of action: / _/_ Address: City:_ State:_ Zip: Dates of attendance: From: / / To: / / Description of events: You must arrange for the appropriate agency or institution to submit all official documentation and correspondence regarding any probation, termination, leave of absence, withdrawal, failure to complete or requirement to repeat directly to the Board. QUESTIONS #18 & 19 License application withdrawal, denial or license surrender Attach additional pages with same format where necessary. Describe circumstances under which license application was withdrawn or denied, or license was voluntarily surrendered. State: Year: / / You must arrange for the appropriate agency or institution to submit copies of all official documentation and correspondence regarding the withdrawal, denial or voluntary surrender directly to the Board. Such documentation must specify the reason(s) for denial or withdrawal of your license application or voluntary surrender of your license application. Signature: Date: / /

20 PRINT NAME: Page 2 QUESTIONS #22, 23, 24 & 25 Medical staff membership, status and/or privileges Attach additional pages with same format where necessary. Describe circumstances leading to change in medical staff membership, status and privileges: Name of facility:_ Date of action : / / Address: City: State: Zip: Description: You must arrange for the appropriate agency or institution to submit copies of all official documentation and correspondence regarding any affirmative responses to Questions 22, 23, 24 and 25 directly the Board. QUESTION #26 Criminal proceedings Attach additional pages with same format if more than one charge and where otherwise necessary. Court:_ Charge: Date: / / Please attach a detailed account of circumstances leading up to criminal proceedings. Status: You must arrange for your lawyer or the court officer to submit copies of the police report, indictment, complaint and judgment or other disposition in any criminal proceedings in which you were a defendant directly to the Board. QUESTION #27 Controlled substances privileges Attach additional pages with same format where necessary. Type of restriction: Date: / / Circumstances of restriction: You must arrange for the appropriate agency or institution to submit a copy of all official orders, findings of fact and correspondence related to any affirmative response directly to the Board. Signature: Date: / /

21 PRINT NAME: Page 3 QUESTIONS #28 & 29 Malpractice claims and other lawsuits You must provide the following information on this form for each instance of alleged malpractice. You may photocopy this form and attach additional copies, if necessary. You must also complete the back of this form. Please print legibly. Claimant s name: Date of incident: / / Insurer s name: Insurer s address: Description of alleged basis (es) of claim (allegations only: this does not constitute an admission of fault or liability). (See Basis for Allegation on page 7.) Allegation Allegation Allegation REQUISITE DESCRIPTIVE INFORMATION: 1. Patient s condition at point of your involvement:_ 2. Patient s condition at end of treatment: 3. The nature and extent of your involvement with the patient:_ 4. Your degree of responsibility for the course of treatment leading to the claim: 5. If incident resulted in patient s death, indicate cause of death according to autopsy or patient chart: Incident location (check one): 01 Emergency Room 02 Labor/Delivery 03 Laboratory/X-ray/Testing 04 Operating Room 05 Outpatient 06 Patient Room 07 Hospital-Other 08 Hospital-Unknown 09 HMO 10 Clinic 11 Nursing Home 12 Physician s Office 13 Walk-in Center 14 Other 15 Unknown Your role (check one): 01 Anesthesiologist 02 Primary Care Physician 03 Referring Physician 04 Attending Physician 05 Consultant Specialist 06 Surgeon 07 Fellow 08 PGY 7 09 PGY 6 10 PGY 5 11 PGY 4 12 PGY 3 13 PGY 2 14 PGY 1 22 Acupuncturist 26 On-call Physician 27 Worker s Comp 28 Court Psychiatrist 24 Group Practitioner/Partner 99 Unknown Evaluator 98 Other (continued on next page)

22 Page 4 QUESTION #28 & 29 - Malpractice claims & other lawsuits, continued Legal representative s name: Address: Telephone: City: State: Zip: Current status of claim: Closed Pending Was the case resolved before the entry of a verdict? Yes No What was the decision? Dismissed before trial Plantiff Verdict Defense Verdict Decision determined by: Judge Jury If a payment was made: Amount allocated to you: $ Payment Date: / / In addition to the information listed above, you must arrange for your lawyer or liability carrier to submit a copy of the following documents directly to the Board for the following malpractice cases: Open case a copy of the complaint naming the physician as a defendant. Closed case a copy of the complaint and final judgment, settlement and release or other final disposition of each claim, even if you were dismissed from the case by the court and/or if the case was closed with or without prejudice and the amount of monies paid on your behalf. Dismissed case a copy of the dismissal if you were dismissed before the case was reviewed by a tribunal or jury. The dismissal must include the name or initials of the patient and confirmation that no monies were paid on your behalf. NOTE: Please be advised that the Board may request pertinent medical records or additional information. Signature: Date: / /

23 PRINT NAME: Page 5 CONFIDENTIAL MEDICAL INFORMATION QUESTION #30 & 31 Medical condition If you answered yes to Questions #30 or 31, please set forth the specifics of your condition and any related treatment, including dates and diagnoses. In addition, set forth 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. You must arrange for your physician to send directly to the Board an evaluation of your current medical status, noting diagnosis, prognosis, treatment plan, and impact of condition on ability to practice medicine. This evaluation must be performed no more than three (3) months prior to the date of your application. At a later date, you may be asked to submit additional information, including documentation of compliance with any monitoring program. QUESTION #32 Use of chemical substances If you have obtained medical treatment related to your use of chemical substances, set forth the specifics of your treatment, including dates and diagnoses. In addition, set forth any adjustments or interventions you may have made or taken to ameliorate or address the impact of your use of chemical substances on your current practice, including participation in any supervised rehabilitation program or monitoring program. You must arrange for your physician to send directly to the Board an evaluation of your current medical status, noting diagnosis, prognosis, treatment plan, and impact of condition on ability to practice medicine. This evaluation must be performed no more than thirty (30) days prior to the date of your application. You must also arrange for the appropriate institutions to submit all discharge summaries regarding any alcohol or drug dependency directly to the Board. At a later date, you may be asked to submit additional information, including documentation of compliance with any monitoring program. Signature: Date: / /

24 PRINT NAME: Page 6 QUESTION #33 Refusal to take screening test If you answered yes to Question #33, please set forth a description of the circumstances leading to the refusal to take the screening test and any resulting criminal or disciplinary consequences. QUESTION #34 Illegal use or misuse of drugs List chemical substances: Describe frequency of usage: Please note that additional information may be requested by the Board. QUESTION #35 Voluntary modification of scope of practice Describe circumstances leading to modification of practice: Describe modification of practice: Dates: From: / / To: / / Please note that additional information may be requested by the Board. Signature: Date: / /

25 BASIS FOR ALLEGATION ABUSE OF (PATIENTS, EMPLOYEE(S)/PEER(S Abuse of Employee(s) /Peer(s) - Physical Abuse of Patient(s) - Physical Sexual misconduct Sexual misconduct - Verbal ADMINISTRATIVE PROBLEMS Academic research fraud Billing for services not rendered Billing fraud (not Medicaid/Medicare) Breach of confidentiality False or deceptive advertising Inadequate documentation/patient records Insurance balance billing (not Medicaid/Medicare) Medicaid/Medicare Medicaid/Medicare balance billing SUPERVISION Fully licensed physician Limited licensee (e.g. resident) Nurse or other employee Physician's assistant DIAGNOSIS RELATED Delay in diagnosis Failure to Diagnose Abdominal problems (not appendicitis or ulcer) AIDS/AIDS Related Complex/HIV Appendicitis Bladder problem Bone cancer Bowel problem Breast cancer Cancer (unspecified) Cardiac disorder (notmyocardial infarction) Circulatory problem Colon/rectal cancer Diabetes Eye disorder Fracture/Dislocation Gall Bladder disorder Genetic disorder Hemorrhage Hernia Hodgkin's disease Implanted foreign body Infection Kidney disorder Liver disorder Liver/kidney/pancreas cancer Lung cancer Lyme disease Meningitis Myocardial infarction Neurological disorder Orthopedic problem (not fracture/dislocation) Ovarian/cervical cancer Pneumonia/pneumothorax Respiratory problem Skin cancer Tendon injury Testicular torsion Testicular/prostate cancer Tumor Ulcer or complication(s) of ulcer Failure to perform diagnostic test(s) Lack of informed consent Misdiagnosis Ordering/performing unnecessary diagnostic tests/procedures BIOMEDICAL EQUIPMENT/PRODUCT RELATED Malfunction Misuse TREATMENT RELATED Abandonment of patient Delay in treatment Failure to make referrals appropriately Failure to monitor patient Failure to notify patient of test results Failure to take adequate patient history Failure to treat Failure to use consultants appropriately Improper choice of treatment Improper treatment of fracture/dislocation Inappropriate admissions(s) Inappropriate discharge(s)/transfer(s) Lack of informed consent Anesthesia Related General Allergic/adverse reaction Failure to test improper use of equipment Improper intubation Improper positioning of patient Lack of informed consent Teeth damage Wrong amount/type of anesthesia prescribed Intravenous Related CVP line Dye reaction General Infiltration Lack of informed consent Medication Related Drug side effect Drug toxicity/overdose Failure to diagnose drug addiction Failure to diagnose drug related problem(s) (not addiction) Failure to prescribe General Lack of informed consent Prescribing to a known addict Wrong dose of medication ordered/administered Wrong medication ordered/administered Mental Illness Related Failure to diagnose mental disorder/illness/problem Failure to warn third party(ies) General Improper commitment Improper use of seclusion/restraints Lack of informed consent Suicide/suicide attempt by inpatient Suicide/suicide attempt by outpatient Obstetrics-Gynecology Related Failed sterilization Failure to diagnose ectopic pregnancy Failure to diagnose Pregnancy, normal Fetal death/stillbirth Gynecology-general Improper performance of abortion Injury to child during labor/delivery Injury to mother during labor/delivery Lack of informed consent Maternal death related to delivery Obstetrics-general Wrongful life/birth Page 7 Surgery Related Delay in surgery General Failure to diagnose post-op complications Improper treatment of post-op complication Improper/negligent performance Laceration/penetration not within scope of surgery Lack of informed consent Positioning-not anesthesia Retained foreign bodies (e.g. needle, sponge) Unnecessary surgery Wrong body part or wrong patient Specified Procedures/Specialties Angiography/arteriography Biopsy CAT scan/mri Catheterization Chemotherapy Circumcision Colonoscopy Endoscopy Injection/Immunization Laparoscopy/laparotomy Myelography Neonatology Neurology Orthopedics Pediatrics Plastic/cosmetic surgery Radiation therapy Stress test Suturing TRANSFUSION RELATED Caused AIDS/HIV Caused hepatitis Mismatch MISCELLANEOUS Improper utilization review Improper Workmen's Compensation evaluation Patient fall (in health carefacility/office) Performance of autopsy without permission Unauthorized DNR order Vicarious liability for acts of another provider Violation of patient's civil rights Wrongful death of patient

26 LIMITED LICENSE APPLICANT FORM A Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: MEDICAL EDUCATION VERIFICATION FORM A APPLICANT INSTRUCTIONS: Please complete the waiver for release of information and forward this form to your university/medical school(s) or university of graduation for verification. Please Note: Fourth year medical students must include the letter to the medical school registrar and Form B. Waiver for Release of Information I authorize the medical school/university listed below to provide any and all information pertaining to my medical education at your institution. Applicant s Signature: Date of Birth / / Print or Type Name: Social Security No: (Last name) (First Name) (Middle Initial) Other Name(s) (Please type or print name(s) Name of Medical School: Address: City: State or Province: INSTRUCTIONS TO THE DEAN OR DESIGNATED OFFICIAL OF MEDICAL SCHOOL Please complete Form A and complete Form B if the above named applicant has not been awarded a degree. Please include a copy of the official transcript (which indicates courses taken, dates and hours of attendance, scores, grades, or evaluations) and return to the applicant in a sealed envelope. Please sign or stamp across the seal on the envelope. APPLICANT S EDUCATIONAL HISTORY If name of institution was different from the above named institution when applicant attended, please enter name below: Premedical Education: Does your school have a premedical school education requirement? Yes No If yes, indicate where the applicant completed premedical school. Applicant s Undergraduate School: Undergraduate School Address: Continued on page 2

27 LIMITED LICENSE APPLICANT FORM A Enrollment and Participation: Our records indicate that (type or print the applicant s name): (Last name) (First name) (Middle initial) attended our medical school on the following dates (indicate the month, day and year in the section below): ATTENDANCE DATES: FROM TO FROM TO / / / / / / / / / / / / / / / / / / / / / / / / The applicant attended total weeks (must be included) of continuing on-campus education, not less than 32 weeks in each academic year check one was awarded a degree in on (month/day/year) / / will be awarded on / / (Form B must also be completed and returned directly to the Board) Unusual Circumstances: The following questions apply to unusual circumstances that occurred during any part of the applicant s medical education. All questions must be answered. If you answer YES to any of the questions below, please enclose an explanation. 1. Did the applicant take any leaves of absence or breaks from his/her medical education? (Explain personal leaves.) 2. Was the applicant ever placed on probation? 3. Was the applicant ever disciplined or under investigation? 4. Were any negative reports ever filed by instructors regarding the applicant? COMMENTS: YES NO AFFIX INSTITUTIONAL SEAL HERE (if the institution does not have a seal, this form must be notarized) INTERNATIONAL MEDICAL SCHOOLS MUST ATTACH A COPY OF THE MEDICAL SCHOOL DIPLOMA AND A TRANSCRIPT OR PROVIDE AN EXPLANATION. Signature: Print Name: Title: Date: / / Telephone: ( ) This form will not be accepted unless it is stamped with the institutional seal or notarized.

28 COMMONWEALTH OF MASSACHUSETTS Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: Dear Registrar: The Massachusetts Board of Registration in Medicine (hereinafter the Board ) will not grant a limited license to an applicant unless that applicant has been awarded a medical degree. Since the rationale for the Board s licensing regulations and statutes is to ensure that only qualified applicants are licensed, the Board has determined that an applicant must be awarded a medical degree prior to granting a limited license to practice medicine in Massachusetts. Previously, a medical school verified either an applicant s graduation from medical school or the applicant s anticipated graduation from medical school. We recognize that there are certain circumstances under which an applicant would not graduate, as expected, from medical school, for example: 1) failure to either take or pass Step 2 of the USMLE; 2) uncorrected failing grades in a preclinical course; 3) uncorrected failing or marginal performance in a clinical clerkship; or 4) failure to meet any other curriculum requirements. Therefore, the Board has initiated a new procedure for the verification of medical school education. All applicants must have Form A, copy attached, of the Medical School Verification completed by their medical school. An additional form is required for applicants who are fourth year medical school students and who have completed the requirements for the M.D./D.O. degree, but have not yet been awarded the degree. For these applicants, the medical school must complete Form B of the Medical School Verification form, copy attached. Any state medical board to whom you have certified an applicant s graduation would wish to be notified immediately regarding a medical school s determination that the applicant will not graduate, as reported on Form B. In addition, fourth year medical school students are required to notify the Board within twenty-four hours of notification by the medical school that they have not met the medical school s graduation requirements. The notification form entitled Medical School Status Update is available on the Board s website at The Board appreciates your assistance in making your students aware of these new requirements. Should you have any questions, please contact me at the above listed number. Sincerely, Rose M. Foss Rose Foss Director of Licensing Medical School Verification Letter March 1, 2007

29 Form B Medical School Verification Form Applicants who are fourth year medical school students and who have completed the requirements for the M.D./D.O. degree, but have not yet been awarded the degree are also required to have this form completed by their medical school. Original signature of the Dean or another medical school official is required to complete the requested information. Signature stamps will not be accepted. Any state medical board to whom you have certified an applicant s graduation would wish to be notified immediately regarding a medical school s determination that the applicant will not graduate. Please complete Form A and return it to the sender. This Form B must be sent to the Board of Registration in Medicine after the student completes the degree requirements. My signature below certifies that (Student s Name) has completed the requirements for the M.D. degree D.O. degree from (Name of Medical School) and will receive the degree on /_ /. Signature of Certifying Official: (Original Signature is required Stamps not accepted) Printed Name: Title: Date: Please return the completed Form B to the Limited License Coordinator, Board of Registration in Medicine, 200 Harvard Mill Square, Suite 330, Wakefield, MA Telephone: (781) Fax: (781) Thank you Medical School Verification form Form B March 5, 2007

30 LIMITED LICENSE APPLICANT Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: massmedboard.org STATE LICENSE VERIFICATION Applicant s Instructions: Complete the waiver for release of information and forward this form to every state board where you are currently licensed or were ever licensed in the past. Contact the individual state board(s) for information on verification processing fees before you mail this form. Applicant s Waiver for Release of Information: I am applying for licensure in the Commonwealth of Massachusetts and the Board of Registration in Medicine requires that this form be completed by each state where I hold or have ever held licensure. I hereby authorize the release of any information in your files, favorable or otherwise. Signature of physician: Date: / / Print or type name: License number: Status of license: Active Inactive Other TO BE COMPLETED BY STATE BOARD 1. Name of medical school of graduation: 2. Date of graduation: / / License number: Date of issue: / / 3. Basis for licensure: Name(s) of medical licensing examinations(s). 4. Expiration date of license: / / 5. Status of license: (check one) good standing revoked suspended 6. If revoked or suspended, please explain: 7. Has the licensee ever been on probation? 8. Has the licensee ever been requested to appear before the board? If yes, please explain: Other derogatory information: YES NO Remarks: BOARD SEAL Signed: Print Name: Title: State Board: Date: / / Revised: 9/19/2002

31 LIMITED LICENSE APPLICATION Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Website: massmedboard.org EVALUATION FORM 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: / / Please PRINT your name Name of facility: State INSTRUCTIONS TO THE CHIEF OF SERVICE OR PROGRAM DIRECTOR WHO MUST BE A PHYSICIAN: Please complete the questions below and forward this form to the applicant. 1. How long have you known the applicant? From: / / To: / / A. In what capacity colleague affiliated in practice other: B. Date(s) of applicant s affiliation at facility: From: / / To: / / C. Applicant s Status: Intern Resident Fellow Staff Member Other 2. Has the applicant's privileges to admit or treat patients ever been modified, suspended, reduced or revoked? No *Yes (if "yes" please explain below) 3. Please rate the following (if "BELOW AVERAGE or "POOR", explain in detail on the back of this evaluation and/or attach a separate sheet) Clinical knowledge Clinical competency Professional judgment Character and ethics Technical skills Relationships with staff Relationship with patients Cooperativeness/ability to work with others Superior Above Average Average Below Average Poor (Continued on page 2) Page 2

32 4. Has this applicant ever been the subject of disciplinary action or had staff privileges, employment or appointment at this hospital or facility voluntarily or involuntarily denied, suspended, revoked or has (s)he resigned from the medical staff in lieu of disciplinary action? If yes please explain below. NO YES 5. PLEASE COMMENT ON THE PHYSICIAN S STRENGTHS OR WEAKNESSES AND/OR ANY OTHER INFORMATION THAT YOU MAY HAVE TO ASSIST IN THIS EVALUATION. 6. The above comments are based on the following: Close personal observation General impression A composite of previous evaluations by other physicians Other 7. RECOMMENDATIONS: I recommend for licensure in Massachusetts. I recommend Massachusetts, with the following reservations for licensure in I do not recommend Massachusetts for licensure in I certify that at the time of completion of the above physician's training, and/or during my assocation with the physician, he/she was competent to practice medicine. Signature: (check one) M.D. or D.O. Print Your Name: Date: / / Academic title or position: Phone number: Specialty/Service or Department: Please return this completed form to the applicant in a sealed envelope, signed or stamped across the seal. Thank you.

33 Limited License COMMONWEALTH OF MASSACHUSETTS--BOARD OF REGISTRATION IN MEDICINE 200 Harvard Mill Square, Suite 300, Wakefield, Massachusetts AUTHORIZATION FOR RELEASE OF INFORMATION, DOCUMENTS AND RECORDS I, (type/print your complete name) 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 further request and authorize that the requested information, documents and records be sent directly to: Board of Registration in Medicine Harvard Mill Square, Suite 330 Wakefield, MA Telephone: (781) Fax: (781) Attention: Licensing Immunity and Release 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. By my signature below, I acknowledge that information, documents and records required to be furnished by another organization, educational institution, hospital, individual or any person or groups of persons has been sent to me directly from the primary source in a sealed envelope and that none of the seals have been broken. A photocopy or facsimile of this authorization shall be as valid as the original and shall be valid up to one year from the date signed. Applicant s Signature Date of Signature Applicant s Printed Last Name, First Name, Middle Initial, Suffix (e.g., Jr.) Applicant s Date of Birth (month/day/year)