Medical Board INSTRUCTIONS

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Medical Board

INSTRUCTIONS

FOR COMPLETING YOUR LICENSE APPLICATION

Introduction
Fees to Be Submitted
How to Fill Out the Application
Personal History Questions
Documents to be Submitted by the Applicant
Disciplinary Inquiry Forms
Verifying Your Credentials
Medical Practice Act & DEA Laws - Open Book Examination

INTRODUCTION

Please be advised that fraud or misrepresentation in applying for or procuring a license to practice medicine or podiatry in Oregon is grounds for denial of your application. The applicant must pay fees or charges for court documents, hospital records or other required documents or reports.
Complete the application yourself. Do not delegate this important task to someone else. If you do and the information on the application is not correct, it will delay the processing of your application and could delay the Board granting you a license to practice in Oregon.
Take your time and read the instructions and the form carefully. Do not rush through the application.
All applicants, despite the basis used to obtain licensure, must complete all forms that pertain to the applicant's history. Licensure is not granted solely on passing a licensure examination, and passing a licensure examination does not assure issuance of an Oregon license.
Information must be completed on the original application form sent to you in the mail or downloaded from the Board's web site; a copy is not acceptable.
The application form, fee(s), and documents submitted to the Board will not be returned to you. For your own records and for reference during the licensure process, keep a copy of your application and all forms that you send to a third party.
Provide full details and dates, and complete names, addresses and zip codes where requested.
Each item on the application form must be completed. If an item of information is not relevant to your application, please write in "Not Applicable" or "N/A".
If additional space is needed to answer any of the questions on the application, please continue on a separate sheet, indicate to what question your response is relevant, print your name, sign and date it, and submit it with the application form.
The Board must receive all application materials and supporting documentation in the mail or you may hand deliver them to the Board office. The Board does not accept faxed documents.
The following information is provided in order to assist you in answering the questions on the licensure application. Please review your completed application prior to mailing it to the Board to be sure all items have been completed. Incomplete or incorrect information will delay the processing of your application. You are responsible for the contents of your application even though someone else may assist you in its completion.

FEES TO BE SUBMITTED AS A PART OF THE LICENSURE PROCESS

Required fees may be paid by personal check or by credit card (Visa, MasterCard, and Discover card only)
Fees are set by law and administrative rule. No exceptions are made to the fees shown.
Read eligibility requirements carefully. Once fees are submitted, they will not be refunded, credited, transferred or prorated.
The application processing fee is required before the board begins the processing of your application. Once received, the application form and fee are valid for a period of one year from the date received. If licensure is not obtained within that one-year period, a new application and processing fee must be submitted as if filing for the first time to continue the licensure process. The applicant is required to meet current licensure requirements.
The application/processing fee is due so that the board may review your application form, update by computer information received for your file, maintain the Online Status Report service, provide you with your formal license, certificate of registration once licensed, etc. The application fee for licensure does not include your initial registration fee.

*APPLICATION PROCESSING/FILING FEE:*
	MD/DO Applicant	$375.00	Pay this fee with the application form
	DPM Applicant	$340.00	Pay this fee with the application form

	Do not pay fees listed below until you are requested in writing to do so. You will receive the proper forms to use when submitting the fees shown below.

*LIMITED LICENSE FEE:*
There is a separate form and fee due in order to be issued a Limited License, Special or Limited License, SPEX which will allow you to work prior to the next quarterly Board meeting. The application may be sent after the Unlimited license application has been received with fee and the applicant has been determined to be eligible for the Limited License.

	Limited License, Special	$185.00	Pay this fee with the limited license form
	Limited License, Spex	$185.00	Pay this fee with the limited license form

INITIAL MD/DO/DPM REGISTRATION AND BIENNIAL REGISTRATION FEES:
Initial registration fees are due prior to licensure being granted, either for two years (if licensed in first year of biennium), or for one year (if licensed in second year of biennium). After initial licensure, biennial registration fees are due to maintain your Oregon license.

Active/Locum Tenens	$438.00	Biennial fee	Pay this fee with the registration form
Emeritus	$50.00	Annual fee	Pay this fee with the registration form
(Volunteer Non-Remunerative Practice)

MD/DO/DPM in residency training (in-state or out-of-state) may register on an annual basis.
Applicants for licensure must pay the first biennial registration fee in advance of the license being issued, to avoid delay in licensure.
Oregon uses a biennial registration period for MD/DO/DPM’s -- from January 1 of every even-numbered year through December 31 of every odd-numbered year. Example: 1/1/04 - 12/31/05.
Applicants receiving an initial license during the first year of the biennium pay the total fee due ($438.00). Applicants receiving an initial license during the second year of the biennium pay one half of the total fee due ($219.00).

Other Fees:

If an applicant is required to take the SPEX examination, all fees due to take this examination will be requested by and paid directly to the Federation of State Medical Boards. SPEX examination fees should not be submitted to the Oregon Medical Board.

Verification Fees -- State Boards, Hospitals, Medical Schools:

Any fees requested by an agency to provide a verification of licensure, training, graduation, etc., are the responsibility of the applicant.

Information Required Due To Affirmative Personal History Question Responses:

If an applicant has answered any Personal History Questions in the affirmative, it is the applicant's responsibility to pay any fees required, (including fees for court documents, hospital records, copying information, etc.) which may be due as a part of the application process.

HOW TO FILL OUT THE APPLICATION

Item 1	-	Full legal name as it appears on Birth/Marriage certificate or naturalization/name change documents only

Item 2	-	Show any names you have used professionally in the past or other names you have been known by

Item 3	-	Training or practice address; this may be a hospital if you are continuing your postgraduate training

Item 4	-	Residence address

Item 5	-	Other address (use this section only if you wish your mail to be sent to a locum tenens agency, a relative, etc.)

		Mail will be sent to the address you designated for mailing purposes. Please arrange to have mail forwarded to you. Review your Online Status Report closely for items still needed to complete your file.

Item 6	-	Practice/training telephone number (office, clinic, hospital, etc.) with proper area code and extension

Item 7	-	Residence telephone number with proper area code

Item 8	-	Other telephone number with proper area code

Item 9	-	E-mail address. Provide your e-mail address if you wish to receive e-mail communications on the status of your application as it progresses through the application process. Please be aware that e-mail is not a secure medium of communication and that e-mail may contain confidential (personal) information.

Item 10	-	Social Security Number required. As part of your application for license or renewal of your registration you are required to provide your Social Security Number to the Oregon Medical Board. This is mandatory. The authority for this requirement is ORS 25.785, ORS 305.385, 42 USC § 666(a)(13), 42 USC § 405 (c)(2)(i) and 45 CFR § 61.7 (3)(b). Failure to provide your Social Security Number will be a basis to refuse to issue or renew the license, certification or registration you seek. Your Social Security Number will remain on file with the Board and will be used for child support enforcement by Child Services Division, for tax administration and required reports to the National Practitioner Databank and the Healthcare Integrity and Protection Databank (NPDB-HIPDB). The Board may also use your Social Security Number for identification and investigative purposes and for the collection of delinquent fines assessed by the Board.

Item 11	-	Premedical/preosteopathic/prepodiatric school - name, location, beginning and ending dates, degree and date obtained.

Item 12	-	Information on additional premedical/preosteopathic/prepodiatric education, if any.

Item 13	-	Name and location of all medical/osteopathic/podiatric schools attended, with beginning and ending dates of attendance for each year enrolled, showing repeated years, or gaps in education or leaves of absence.

Item 14	-	Name and location of medical/osteopathic/podiatric school you graduated from, with date of graduation, and degree obtained (MD/DO/DPM).

Item 15	-	Indicate which licensure examination(s) you have taken. Indicate other examination(s) taken such as ECFMG/FMGEMS or SPEX.

Item 16	-	List ALL licenses ever applied for whether they are pending, active or inactive, temporary (for training), or have been denied, suspended or revoked, or your application was withdrawn. Provide full written explanation if you have had a license denied, suspended, or revoked, or if you withdrew an application for licensure.

Item 17	-	Indicate whether you have previously applied for and been granted a limited or unlimited license, and if yes, the license number and date licensed.

Item 18	-	List all hospitals in which you have ever applied for staff privileges for practice or military service, from the date of medical school graduation to the present date. The list should include the beginning and ending dates, complete names and addresses and zip codes of the hospitals and other required information. Do not include hospital training programs. Verifications are required for the past five (5) years only.

Item 19	-	Account for all periods of time since you graduated from medical/osteopathic/podiatric school to the present date. This should include any non-medical activities, vacations, (of one month or longer and only between activities), training, or postgraduate work, private practice, staff positions or locum tenens. It should include the beginning and ending dates, complete names, addresses and zip codes and the type of training or postgraduate work, or hospitals, clinics and the type of position-employment held in each location. Indicate the number of physicians in the group or clinic and the name of the clinic manager or director, if applicable.

Personal History Questions

PERSONAL HISTORY QUESTIONS If you answer "YES" to any personal history question, please furnish details on the form provided by the Board, sign and date it, and submit it with your application. The source must submit a letter and/or documents relevant to the situation directly to the Board. Failure to provide all details will delay the processing of your file.

Item 20

Personal History Questions - CATEGORY I

Question 1
	*Applicant*	Provide full details to include date of licensure, license number, type of license, and current status of the license.
	*Licensing Board*	Provide verification of licensure to include license number, date issued, and current status.

Question 2
	*Applicant*	Provide full details to include state/province, type of examination failed, and dates and grades (if known) for each failure.
	Examination Agency	The report of examination grades will verify any failed attempts.

Question 3
	*Applicant*	Provide full details to include state/province, reasons/circumstances and any disciplinary action.
	*Licensing Board*	Provide full details and include copies of any legal documents.

Questions 4, and 5
	*Applicant*	Provide states, dates and reasons/circumstances.
	*Licensing Board*	Provide full details and include copies of any legal documents.

Question 6
	*Applicant*	Provide full details including dates and reasons/circumstances, and provide a copy of documents, reports and correspondence.
	*State Narcotic Office/Drug Enforcement Administration (DEA)*	Provide full details and include copies of any legal documents.

Question 7
	*Applicant*	Provide full details of the arrest, the dates, places, and disposition of the case.
	*Police Department/ Court*	Provide a Certified Copy (with court seal affixed) of the original charge, the judgment, the sentence and/or the dismissal order or other such documents which reflect the disposition of the matter.

Question 8
	*Applicant*	Provide full details to include the agency conducting the investigation as well as the reasons for the criminal, civil, or licensing investigation. Provide a copy of documents, reports and correspondence.
	*Investigating Agency*	Provide full details concerning reasons for the investigation.

Question 9
	*Applicant*	Provide full details to include details of the case, where/when incident occurred, disposition of the case, judgment, etc. Please indicate if the case is still pending. Provide a copy of the documents, reports and correspondence.
	*Investigating Agency*	Provide full details concerning reasons for the investigation.

Question 10
	*Applicant*	Provide full details to include the agency/party with which the settlement was entered as well as the reasons for and conditions of the settlement. Provide a copy of the documents, reports and correspondence.
	*Agency/Party*	In some cases information is needed in addition to the applicant's explanation. (see above)

Question 11
	*Applicant*	Provide full details to include name of patient, where/when incident occurred, disposition of the case, judgment, etc. Please indicate if the case is still pending. Provide a copy of the documents, reports and correspondence.
	*Malpractice Carrier/Court*	In some cases information is needed in addition to the applicant's explanation. (see above)

Question 12
	*Applicant*	Provide the length of time you did not practice medicine or ceased the practice of your specialty and the reason why, as well as your activities, (medical or non-medical) for that period of time.
	*Hospital/School/* *Training Program*	In most cases, the applicant’s explanation is all that is needed concerning an affirmative response to question 12. However, in some cases the applicant will be asked to request information be sent directly from other sources to the Board.

Question 13
	*Applicant*	Provide name of the medical/osteopathic/podiatric school, training program, dates and reasons/circumstances.
	School/ Training Program	Provide full details concerning the circumstances, results, and copies of any legal documents.

Question 14
	*Applicant*	Provide full details to include the name of the hospital, clinic, surgical center, dates, and reasons/circumstances.
	*Hospital/ Employment*	Provide full details including dates, circumstances, results, and copies of any legal documents.

Item 20

Personal History Questions - CATEGORY I I

Question 1
	Applicant	Provide full details and dates regarding treatment received for the condition. If any medications were prescribed, furnish the names, dosages and the dates the medications were taken. Include the names and addresses of the treating psychiatrist, psychologist, social worker, clinical therapist, or counselor and dates of treatment, or therapy. Request the person providing treatment send directly to the Board complete details of treatment or counseling including dates, diagnosis (if any), treatment and prognosis.
	Source	Provide a full report to include Family History/Physical; Individual Assessment and Evaluation; Psychiatric Evaluation; Psychosocial Assessment; Discharge Summary and Discharge Plan for Continued Care or the equivalent. Letters/reports to be sent directly to this Board.

Question 2
	Applicant	Provide full details and dates regarding this treatment. If any medications were prescribed, furnish the names dosages and the dates the medications were taken. Include the names and addresses of the treating psychiatrist, psychologist, social worker, clinical therapist, or counselor and dates of treatment or therapy. Request the person providing treatment send directly to the Board complete details of treatment or counseling including dates, diagnosis (if any), treatment and prognosis.
	Source	Treatment provider to furnish complete details of treatment or counseling Including dates, diagnosis (if any), treatment and prognosis. Request the Appropriate official at the hospital send directly to the Board a full report to include Family History/Physical; Individual Assessment and Evaluation; Psychiatric Evaluation; Psychosocial Assessment; Discharge Summary and Discharge Plan for Continued Care or the equivalent. Letters/reports need to be sent directly to this Board.

Question 3
	Applicant	If you received treatment for this dependency, provide full details and dates regarding this treatment. Include the names and addresses of the treating psychiatrist, psychologist, social worker, clinical therapist, or counselor and dates of treatment or therapy. Request the person providing treatment send directly to the Board complete details of treatment or counseling including dates, diagnosis (if any), treatment and prognosis.
	Source	Treatment provider to furnish complete details of treatment or counseling Including dates, diagnosis (if any), treatment, and prognosis. Request the appropriate official at the hospital send directly to the Board a full report to include Family History/Physical; Individual Assessment and Evaluation; Psychiatric Evaluation; Psychosocial Assessment; Discharge Summary and Discharge Plan for Continued Care or the Equivalent. Letters/reports to be sent directly to this Board.

Question 4
	Applicant	Provide full details and dates regarding this treatment and/or hospitalization. Include the names and addresses of the treating psychiatrist, psychologist, social worker, clinical therapist, or counselor and dates of treatment or therapy. Request the person providing treatment send directly to the Board complete details of treatment or counseling including dates, diagnosis (if any), treatment and prognosis. If you have been arrested for a DUII or DWI, request for the arresting officer's report and court documents to be sent directly to this Board.
	Source	Provide a full report to include Family History/Physical; Individual Assessment and Evaluation; Psychiatric Evaluation; Psychosocial Assessment; Discharge Summary and Discharge Plan for Continued Care or the equivalent. Police Department/Court to provide a Certified Copy (with court seal affixed) of the original charge, the judgment, the sentence and/or the dismissal order or other such documents which reflect the disposition of the matter. Letters/reports to be sent directly to this Board.

Question 5
	Applicant	If you received treatment related to this chemical substance screening test, provide full details and dates regarding treatment. Include names and addresses of the treating psychiatrist, psychologist, social worker, clinical therapist or counselor and dates of treatment or therapy. Request the person providing treatment send directly to the Board complete details of treatment or counseling including dates, diagnosis (if any), treatment and prognosis.
	Source	Furnish complete details of treatment or counseling including dates, Diagnosis (if any), treatment and prognosis. Hospital report is also needed to include Family History, Physical, Individual Assessment and Evaluation, Psychiatric Evaluation, Psychosocial Assessment, Discharge Summary and Discharge Plan for Continued Care or the equivalent. Letters/reports to be sent directly to this Board.

Question 6
	Applicant	Provide full details and dates to include the name and location of the diversion program, regulatory board, healthcare program or facility, and/or court, and reasons for and results of entering the program.
	Source	Furnish treatment records and any court/legal documents directly to the Board.

Item 21	-	Indicate month, day and year of birth

Item 22	-	Indicate city, state, or country of birth if not in the United States

Item 23	-	Describe your physical appearance.

Item 24	-	Indicate your gender: male or female

Item 25	-	Indicate beginning and ending dates of ALL active duty in the military service.

Item 26	-	If you have a medical specialty, please indicate the specialty. If you are still in training, indicate your anticipated specialty.

Item 27	-	Indicate where you plan to practice (hospital, clinic, with another physician, solo practice), the practice address, and the beginning date of practice. If your place of practice is undecided, indicate “undecided.”

Item 28	-	Indicate date you plan to begin training in the state of Oregon, as well as the type of training (residency, fellowship), and the name of the hospital where training is to be obtained.

Item 29	-	Provide information on initial certification and recertification by an American Specialty Board recognized by the American Board of Medical Specialties, the American Osteopathic Association’s Bureau of Medical Specialists, the American Board of Podiatric Orthopedics & Primary Medicine, and the American Board of Podiatric Surgery.

Photograph: Attach photograph in this space by stapling it to the application. Photograph should be an original of passport quality, a close-up front view of head and shoulders (not a profile). Photograph must be taken within 90 days prior to applying, signed in ink on the front, showing date taken. Photograph may not be computer generated or scanned.

Release/Affidavit of Applicant: You must complete this affidavit in the presence of a Notary Public. The Notary Public must sign, date, and affix seal to the affidavit. The notarization must be placed directly on the application.

DOCUMENTS TO BE SUBMITTED BY THE APPLICANT

Size of Documents: Documents submitted must be legible, and no larger than 8 1/2 x 11 inches, and no smaller than 5 x 7 inches. If the original document is larger or smaller than this, please have the copy reduced or enlarged to 8 1/2 x 11 inches to show all wording, dates and signatures.

Copies of Original Documents: Do not submit original documents. Copies do not need to be notarized. Any documents submitted become a part of your file and will not be returned to you. Xerox copies of documents are acceptable, but must be legible. Translations of foreign documents are required (see below).

Official Translations: If any of your documents are in a foreign language, this Board requires you to furnish an official, word-for-word translation of that document. Acceptable translators are an employee of a professional translating company, or a member of the American Translation Association, or a faculty member of the modern languages or linguistics department of a United Sates college or university. The translation must be on official letterhead, and bear the translator's certification seal. Translations will not be returned to the applicant. All information appearing on the document must also appear on the translation each time it appears on the original document. This includes pre-printed information, such as the letterhead of a university, titles, etc. The translation must be attached to the copy of the document being translated. The applicant is required to pay for all translated documents.

Birth Certificate:
Provide a copy of official birth certificate or birth record. Hospital birth certificates are not acceptable. Your application must show your complete, legal name including Jr., II, III, initial only, or no middle name. Your complete, legal name will be shown on your formal license, and all licensees must pursue their profession under their own name as it appears on the license. A copy of your passport, driver's license, etc., does not meet this requirement and cannot be accepted in lieu of the required birth certificate.

Change of Name/Marriage Certificate:
A copy of Change of Name documentation, Marriage Certificate, or Divorce Decree if your name has been changed by court order, adoption, marriage, divorce, etc.

If you have had a name change due to marriage, divorce, adoption, court order or naturalization, furnish a copy of all applicable documents as follows:

Marriage	furnish a copy (no larger than 8 1/2 x 11 inches)	of your marriage certificate
Divorce	furnish a copy (no larger than 8 1/2 x 11 inches)	of your divorce decree
Adoption	furnish a copy (no larger than 8 1/2 x 11 inches)	of your adoption papers
Court Order	furnish a copy (no larger than 8 1/2 x 11 inches)	of your name change
Naturalization	If you have had a name change by naturalization, inform the Board in writing and a form will be sent for you to complete and sign.

If any of your documents are in a foreign language, you must also furnish an official translation attached to the copy of the document.

Naturalization Affidavit Form:
Since it is a violation of law to copy a Naturalization document, the Oregon Board requests that you complete a form (provided by the Board) stating the naturalization number and date and place of naturalization. If your name has changed due to naturalization, please so advise when you file your application, and we will send you the required form for completion. Do not submit a copy of your naturalization paper.

Fingerprint Cards:

Pursuant to ORS 677.265 (9), applicants for licensure by the Oregon Medical Board must provide fingerprints as set forth in the above mentioned statute in order for the Board to conduct a state and federal criminal history record check. All fingerprints are processed through the Oregon State Police (OSP) and the FBI. Fingerprints must be submitted on form FD-258, which will be mailed to applicants upon receipt of application, or can be obtained from local law enforcement offices.

Fingerprint cards must be completed properly, (example) with all of the identification information filled out according to the instructions. The applicant must sign the card in the presence of the official taking the prints, who will also sign the card. In addition, the official taking the prints must complete an Identification Verification form verifying the identity of the applicant at the time of printing. Fingerprint cards returned to the board without this form will be rejected and applicants will be required to submit new prints – this will delay licensure. Applicants will be required to show picture identification (i.e., driver’s license, state issued identification card, military identification card, passport) at the time of fingerprinting.

Completed fingerprint cards are to be returned to the Oregon Medical Board along with the Identification Verification form. Do not send the fingerprint cards directly to the FBI or OSP.

The prints themselves must be of a quality meeting FBI standards, which are printed on the back of each fingerprint card. If the instructions are not followed, or the fingerprints do not meet FBI standards, the cards may be rejected by the Oregon Medical Board, OSP, or FBI. Rejected cards are sent back to the applicant with new cards for resubmission. This will delay the application process. All applicants are therefore urged to complete this step of the application process early so as not to delay licensure.

Fingerprinting services are available from local law enforcement agencies and can be found under fingerprinting services in the yellow pages. Fees for fingerprinting services may vary.

Questions regarding this procedure can be submitted by email to the Licensing Department at bme.fingerprints@state.or.us.

Medical/Osteopathic/Podiatric Diploma:
A copy of your diploma showing graduation from a school of medicine/osteopathy/podiatry that grants a degree of Doctor of Medicine, Doctor of Osteopathy, or Doctor of Podiatric Medicine. If the diploma is written in a foreign language, furnish an official translation attached to the copy of the diploma.

Fifth Pathway Certificate:
A copy of your Fifth Pathway certificate showing that such a program has been completed. A Fifth Pathway year does not count towards the accredited training required.

American Specialty Board Certificate:
A copy of the certificate issued by the American Specialty Board in your specialty. If certificate is not available, submit a copy of the result letter notifying you of your Diplomat status.

American Specialty Board Recertification Certificate:
A copy of the certificate showing recertification issued by the American Specialty Board in your specialty. If certificate is not available, submit a copy of the result letter notifying you of recertification status.

Letter Requesting Waiver of SPEX Examination:
Physician applicants (MD/DO) are expected to take the SPEX examination if:

Completion of postgraduate training, Board certification or recertification was obtained 10 or more years prior to filing an application for Oregon licensure, or
The applicant ceased practice for 12 or more consecutive months.

If you wish to request a waiver of the SPEX examination, you must submit a request in writing and provide documentation of continuing medical education for the past 3 years, or have a letter sent directly to the Board stating you have been granted an appointment as a professor or associate professor at the Oregon Health and Science University.

Further details for requesting a waiver of the SPEX can be seen at Notice to Oregon SPEX Applicants and Request for SPEX Waiver.

Photograph:
Close-up passport quality photograph, no smaller than 2 inches by 2 inches and no larger than 2 inches by 3 inches, front view, head and shoulders (not profile) taken within 90 days preceding the filing of the application with the applicant's signature and date in ink on the front of the photograph. Photograph may not be computer-generated or scanned. The older Polaroid type photograph with the thick plastic backing is not acceptable, although the newer Polaroid passport photograph is acceptable. Some medical schools require a current photograph for identification purposes. Therefore, we ask that you attach a photograph to the Verification of Medical Education form.

DISCIPLINARY INQUIRY FORMS

Federation of State Medical Boards (FSMB)
MD/DO applicants must either send the FSMB the Disciplinary Inquiries form that is a part of the application packet:
http://egov.oregon.gov/OMB/MD-DO_Application/Disciplinary_Inquires.pdf; or go directly to the Federation web site and download the Board Action Data Bank form, fill it out and submit it to the Federation, so that a disciplinary search can be conducted, and the results mailed to the Board. This is required of all MD/DO applicants for licensure.

MD/DO’s please contact the FSMB at:

Disciplinary Inquiries
Federation of State Medical Boards
P.O. Box 619850
Dallas , TX 75261 -9850
http://www.fsmb.org/fpdc_data_inquiry.html

Federation of Podiatric Medical Boards Podiatrists (FPMB)
DPM applicants must either send the FPMB the form that is a part of the application packet: http://egov.oregon.gov/OMB/MD-DO_Application/Disciplinary_Inquires.pdf; or go directly to the FPMB web site and fill in the form for a disciplinary report, pay the $50.00 fee by credit card or send the FPMB the form with a check. The results of the disciplinary inquiry are mailed to the Board. This is required of all DPM applicants for licensure.

DPM’s please contact the FPMB at:

Federation of Podiatric Medical Boards
6551 Malta Drive
Boynton Beach , Florida 33437
https://www.fpmb.org/orderreports
(561) 752-3735

National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank
ALL MD/DO/DPM applicants for licensure are required to request a Self-Query from the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank and send the results to the Board. The results of the Self-Query will be mailed to you and you must forward them to the Board.
Please access the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank website: http://www.npdb-hipdb.hrsa.gov/. Complete the on-line application for the individual Self-Query request ( http://www.npdb-hipdb.hrsa.gov/welcomesq.html ) which you will submit electronically to the Data Banks. The completed form must also be printed, signed, notarized and mailed to the Data Banks with your credit card information for payment of the $16.00 fee ($8.00 per Data Bank) for the Self-Query. The Data Banks accepts credit card payment only (VISA, MasterCard, Discover card, and American Express). This is the only verification that will be accepted from the applicant, rather than directly from the source.

When you receive the Self-Query report forward both originals (NPDB and HIPDB) to the Oregon Board. The report should be current and have been completed within the past three months. If you have questions you may contact the NPDB-HIPDB at 1-800-767-6732.

VERIFYING YOUR CREDENTIALS

You must request verifications of the following to be submitted directly to the Board office from the source. Verifications must be:

Original
Currently dated. Verifications of employment/practice from where you are currently employed or practicing that are dated more than three months prior to the receipt of your application by the Board must be re-submitted with a current verification.
On letterhead, computer-generated form, or board-provided form.
Faxed responses are not accepted.

Some of the following agencies may require a fee in order to provide the information requested. If you are unsure of the amount, or whether or not a fee is required, it is suggested that you contact the agency directly to determine this, as not submitting the correct fee will delay the response.
If time is short, you may wish to use Federal Express or a similar service to send the required verification forms to the sources for completion. You may also wish to include a prepaid express form for the source to use to expedite a response to this Board.

Verification of Medical Education:
Send the Certificate of Medical Education form to the Dean/Registrar of each medical/osteopathic/ podiatric school attended. The form must be completed fully, showing dates of attendance and exact date of graduation. The form must show any leaves of absence, repeated years, whether the student was accepted as a transfer student, etc. An official of the school must sign the form and the school seal must be affixed.

Dean’s Letter of Recommendation:
This letter is the one already in your medical school file, written by the Dean while you were a student at the school. A copy of this letter directly from your medical school to the board is acceptable. If your school does not or did not produce a Dean’s letter please have the school send a transcript in lieu of the letter.

Clinical Clerkship Verification (International Graduates Only):
If you completed clinical clerkships at an institution in a country other than that in which your medical school was located, fill out and submit the Verification of Clinical Clerkships form to your medical school to obtain verification of your clerkship(s). Send a copy of the form to the Board before you send it to your medical school. If all clerkships were served in the country where your medical school is located, check that option on the form, sign and return form to the Board.

ECFMG/Fifth Pathway:
Please send the Request for Status Report of ECFMG Certification form to the Educational Commission for Foreign Medical Graduates (ECFMG) for verification of your status. This form must be completed by the ECFMG Commission and returned directly to this Board. Verification of your status by the ECFMG and the examinations leading to this certification can also be obtained at

http://www.ecfmg.org/2006ib/ibcert.html#confirmstatus

215-386-5900

info@ecfmg.org

Fifth Pathway:
A letter is required from the Program Director, Chairman or other official of the Fifth Pathway hospital, sent directly to this Board verifying the specific beginning and ending dates of the Fifth Pathway and including an evaluation of overall performance.

Internship/Residency/Fellowship:
A form is enclosed for you to copy and send to the Director of Medical Education, Residency Program Director, Chairman of the Department, or other official of all internship, residency, or fellowship hospitals in the United States and foreign countries where you obtained training. The response received must provide verify specific beginning and ending dates of training and must include an evaluation of over all performance. This information may be provided to the Board on hospital letterhead. The form should be placed in an envelope of the hospital institution that is sending the form.

Private/Clinic Practice/Employment/Locum Tenens Assignments:
A form is enclosed for you to copy and send to the Director or other official of each hospital, clinic, etc., where you were employed or practiced in the past five (5) years, in the United States or foreign countries. This form, or a letter sent directly to the Board, must include specific beginning and ending dates of association as well as an evaluation of over all performance. This information may be provided to the board on official letterhead. The form should be placed in an envelope of the hospital institution that is sending the form. Verifications of employment/practice from where you are currently employed or practicing that are dated more than three months prior to the receipt of your application by the Board must be re-submitted with a current verification. Only employment verification for the past five (5) years is required unless you are advised otherwise by the Board.

Hospital Staff Memberships:
A form is enclosed for you to copy and send to the Director or other official of each hospital in the past five (5) years where you have had staff privileges for practice and locum tenens, for verification of temporary, provisional, courtesy, active, etc. This form must be sent directly to this Board, and must include specific beginning and ending dates of staff membership, an evaluation of performance as well statement as to whether the privileges have ever been restricted, denied, revoked, etc. This information may be provided to the Board on hospital letterhead. The form should be placed in an envelope of the hospital institution that is sending the form. Only verification of privileges for the past five (5) years is required unless you are advised otherwise by the Board.

Verification of Podiatric Hospital Privileges to Perform Ankle Surgery:
Podiatry applicants who wish to be granted an extension to their license to perform ankle surgery in Oregon and who are not Board Certified by the American Board of Podiatric Surgery in Reconstructive Rearfoot/Ankle Surgery must submit this form to the JCAHO approved hospitals where they have current clinical privileges to perform reconstructive/rearfoot ankle surgery.

Locum Tenens:
Applicants must provide the Board with the names and addresses of employment and hospital privileges obtained for all locum tenens and the dates of each. Locum tenens of less than one month do not need to be verified. However, if you return to the same practice several times, a letter would be required. Applicants employed by a locum tenens agency must also request that agency to provide the Board with a list of employment locations (name and address) and a list of hospitals where the applicant has worked.

State or Province Licensure:
A form is enclosed for you to copy and send to an official of the Board in each state or province where you are licensed in the United States or Canada , even if you have never practiced there, and even if your license has lapsed there. This form or a letter (on Board letterhead or computer-generated) must be sent directly from the state or province showing license number, date issued, grades if applicable, disciplinary actions (past and present), and current status with the Board. A certified copy of all legal documents is required. Contact the appropriate board in advance as most charge a verification fee.

Letters from Boards of other professions, such as dental, nursing, physician assistant, etc., are required if you have ever applied for such licensure. Use the form titled Verification of Licensure and Certification of Examination Grades.

You do not need to request a verification of licensure of a temporary license issued for the completion of a training program unless informed otherwise by the Board.

Official Grade Certification:
Contact the National Board of Medical/Osteopathic/Podiatric Examiners, the Medical Council of Canada, or Federation of State Medical Boards and ask that grades be sent to the Oregon Board.

National Board of Medical Examiners (MD)
Applicants for licensure who have completed the National Board of Medical Examiners (NBME ) examination, must request that grades be sent directly to the Oregon Board. Please access the NBME web site at:

www.nbme.org/index.html
Examinee Records Office (215) 590-9700

National Board of Osteopathic Medical Examiners (DO)
Applicants for licensure who have completed the National Board of Osteopathic Medical Examiners (NBOME) examination must request that grades be sent directly to the Oregon Board. Please contact the NBOME at:

National Board of Osteopathic Medical Examiners, Inc.
8765 West Higgins Rd., Ste 200
Chicago , Illinois 60631-4101
(773) 714-0622
www.nbome.org

National Board of Podiatric Medical Examiners (DPM)
Applicants for licensure who have completed the National Board of Podiatric Medical Examiners (NBPME) examination Parts I and II must request that grades be sent directly to the Oregon Board from the NBPME. Please contact the NBPME at:

National Board of Podiatric Medical Examiners
2000 Lenox Drive 3rd Floor

Lawrenceville, NJ 08648
(877) 302-8952
www.nbpme.info

Federation of Podiatric Medical Boards
Applicants for licensure who have completed the National Board of Podiatric Medical Examiners (NBPME) examination Part III must request that grades be sent directly to the Oregon Board from the FPMB. Please contact the FPMB at:

Federation of Podiatric Medical Boards
6551 Malta Dr .
Boynton Beach , FL 33437
(561) 752-3735
https://www.fpmb.org/orderreports

Applicants who have not taken and passed NBPME Part III (all exam fees are payable to Thomson Prometric) can register for the examination by contacting:

Prometric
2000 Lenox Drive 3rd Floor

Lawrenceville, NJ 08648
(877) 302-8952

Medical Council of Canada (LMCC)
Applicants for licensure who have completed the examination administered by the Medical Council of Canada must request that grades be sent directly to the Oregon Board. Please contact the Medical Council of Canada at:

Medical Council of Canada
100 - 2283 St. Laurent Blvd
Ottawa , Ontario , Canada KIG 5A2
(613) 521-6012
http://www.mcc.ca/english/registration/copyresult.html

Federation of State Medical Boards
Applicants who have taken the complete USMLE, FLEX or SPEX examinations must contact the Federation of State Medical Boards (FSMB) and ask that grades be sent directly to the Oregon Medical Board. The Oregon Board currently uses a service offered by the FSMB called eTranscripts, which allows the Board to receive an electronic version of official USMLE, FLEX and SPEX transcripts. This service expedites the process of document submission for applicants. Please access the FSMB web site at:

www.fsmb.org/transcripts.html
(817) 868-4041

MEDICAL PRACTICE ACT AND DRUG ENFORCEMENT ADMINISTRATION LAWS -- STUDY MATERIAL AND OPEN-BOOK EXAMINATIONS CONCERNING THIS MATERIAL

Copies of the Medical Practice Act (Chapter 677), Oregon Administrative Rules (Chapter 847), Practitioner's Manual explaining State and Federal DEA Laws, two open book examinations, and other information related to this material, are included with your application packet. This information is available online for viewing or printing.

Please click on the link or type the URL into your browser’s address bar to access this material: http://www.oregon.gov/OMB/mpadea.shtml

Page updated: August 27, 2008

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