The L For Texas Medical Board form serves as a Physician Licensure Evaluation document required by the Texas Medical Board. This form verifies an applicant's postgraduate training and professional history, ensuring that all necessary evaluations are completed from affiliated facilities within the past five years. Applicants must provide detailed personal information, and evaluating physicians must complete the evaluation to facilitate the licensure process.
The L For Texas Medical Board form, formally known as the Physician Licensure Evaluation, plays a crucial role in the process of obtaining a medical license in Texas. This form serves as a verification tool for postgraduate training and professional history, ensuring that applicants meet the necessary qualifications to practice medicine safely and effectively. Applicants must provide detailed information about their affiliations with various medical facilities over the past five years, including their current full name, date of birth, and TMB ID number. The form also requires evaluations from every facility where the applicant has worked, emphasizing the importance of comprehensive feedback from evaluating physicians. These physicians must hold specific titles, such as Chief of Staff or Medical Director, and are tasked with completing the evaluation section, which assesses the applicant's professional abilities, ethical standards, and overall character. Additionally, the form includes sections dedicated to verifying postgraduate training and professional history, with specific questions aimed at uncovering any unusual circumstances or disciplinary actions that may have occurred during the applicant's career. The confidentiality of the information provided is protected under Texas law, but applicants will have access to their evaluations if their applications are referred to the Licensure Committee. By requiring thorough evaluations and detailed disclosures, the L For Texas Medical Board form aims to uphold the integrity of the medical profession and safeguard public health.
FORM L
Physician Licensure Evaluation – Texas Medical Board
Verification of Postgraduate Training and Professional Evaluation
APPLICANT:
Complete the information in this box. You must have evaluations from every facility with which you have been affiliated in the past 5 years. Note – your licensure analyst may require additional evaluations outside the past 5 years.
Applicant’s Current Full Name: ____________________Name at time of affiliation if different: _______________________
Printed
Applicant’s Date of Birth: ______________
Applicant TMB ID# _________________
Applicant’s Address: ____________________________Telephone: ________________ E-Mail: ____________________
Name of Evaluating Hospital/Institution _________________________________________________________________
Address of Evaluating Hospital/Institution _______________________________________________________________
Dates of affiliation From (mm/yy) ___________ To (mm/yy) _________
Department of Affiliation_______________________
Your position at the time of affiliation:
Intern Resident Fellow Faculty Staff
I hereby authorize all hospitals, institutions or organizations, my references, personal physicians, employers (past, present and future), business or professional associates (past, present and future) and all governmental agencies (local, state, federal, or foreign) to release to the Texas Medical Board or its successors any information, files or records, including medical records, educational records, and records of psychiatric treatment and treatment for drug and/or alcohol abuse or dependency, requested by the Board in connection with this application, necessary to determine my medical competence, professional conduct, or physical and/or mental ability to safely engage in the practice of medicine. I further authorize the Texas Medical Board or its successors to release to the organizations, individuals, or groups listed above, any information, which is material to this application, or any subsequent licensure.
I authorize the release of the information contained in this evaluation form to the Texas Medical Board.
___________________________________________________
Applicant’s Signature
EVALUATING PHYSICIAN:
•A physician who currently holds one of the following positions must complete this evaluation: Chief of Staff, Department Chairman, Medical Director, or Training Director. Letters of recommendation or standard institution verification forms will not be accepted in lieu of this form.
•This completed evaluation should be sent directly to the Texas Medical Board offices via mail, fax, or email.
By mail - Place this form in an envelope of the hospital/institution that you represent, seal the envelope and place your signature over the outside sealed envelope flap. Send to: Texas Medical Board, MC-240, P.O. Box 2029, Austin, TX 78768-2029
By fax - Evaluator must submit the form along with an official hospital/institution coversheet to 888-790-0621. Fax submitted by the applicant and/or without the appropriate coversheet cannot be accepted.
By email - Evaluator must submit the form from an official hospital/institution email address to screen-cic@tmb.state.tx.us. Emails sent from the applicant or from a non-agency email address cannot be accepted.
Title:
Chief of Staff
Evaluating Physician’s
Department Chairman
Medical Director
Name/Degree:
Training Director
Phone:Address:
Fax:E-Mail:
Evaluating Physician's License Number and
State of Licensure
LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION
Version 01.2020
Applicant's Name___________________________________________
Page 2
This is important: All information on this Form L, (including attachments that you provide as the Evaluating Physician) regarding a licensure applicant is confidential pursuant to §164.007(c) of the Medical Practice Act. However, the Board must provide a copy of this Form L and attachments to an applicant when an application is referred to the Licensure Committee for licensure determination. Any information furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity from Civil Liability.
FOR TRAINING POSITIONS – Completion of the Verification of Post Graduate Training and the Verification of Professional History sections are required.
FOR NON-TRAINING POSITIONS – Only completion of the Verification of Professional History section is required.
VERIFICATION OF POST GRADUATE TRAINING
This section relates to postgraduate training. If this individual did not complete postgraduate training at this institution please skip to the Verification of Professional History section.
Department:
PROGRAM PARTICIPATION: (For
PGY: _______
___________________________________
training positions only)
___ Internship
From: ___/___/___
To: ___/___/___
Report incomplete postgraduate years
___ Residency
Credit received?
___ Fellowship
(PGY) separately from those that were
___ Research
Full
*Partial
in progress
successfully completed.
If the postgraduate year is currently in
*For partial credit– how many months?______
progress, report the expected completion
date in the “To” field.
Report Internships, Residencies and
Fellowships separately. Use one section
per department.
UNUSUAL
Yes No
1.
Did this individual ever take a leave of absence or break from training?
CIRCUMSTANCES:
2.
Did this individual resign from training?
(For training
3.
Were any limitations or special requirements placed upon this individual for
positions only)
professionalism or behavioral issues?
Please attach an
4.
Did this individual ever receive a written warning or documented counseling
about his/her behavior?
explanation for any
5.
Was this individual ever placed on probation for any reason?
“yes” response.
6.
Is this individual currently under investigation?
7.
Were this individual’s privileges or duties ever reduced, suspended, or
revoked?
8.
Did this individual experience delayed promotion or delayed advancement to
the next level?
9.
Was this individual informed his/her contract would not be renewed?
10. Was this individual suspended, terminated, or dismissed from training?
Page 3
VERIFICATION OF PROFESSIONAL HISTORY
This evaluation is based on Personal Knowledge
Review of Credential File
How long have you known the applicant? Years________ Months ________
Is the applicant related to you?
Yes
No
Do you know the applicant well?
Has your acquaintance with the applicant continued until recent date?
6.Do you consider the applicant:
(a) Reliable?
(b) Ethical?
(c) Of good character?
7.Please rate the applicant:
Excellent
Good
Average
Poor
(a)Professional ability
(b)Attention to duties
(c)Breadth of education
(d)Interpersonal skills
8.Has applicant, to your knowledge, ever been guilty of:
(a) Fraud or dishonesty?
(b) Unprofessional conduct?
9.To your knowledge, has the applicant ever:
(a) been warned, censured, reprimanded, disciplined, had admissions monitored or privileges limited
or suspended?
(b) had disciplinary action taken against him/her by a licensing agency?
(c) been denied or surrendered a federal or state controlled substance permit?
(d) been arrested, fined, charged with or convicted of a crime, indicted, imprisoned
or placed on probation?
(e) been a defendant in a legal action involving professional liability (malpractice) or had a
professional liability claim paid in his/her behalf or paid such a claim him/herself?
(f) been placed on probation, asked to withdraw, or reprimanded?
(g) been terminated, resigned in lieu of termination or during investigation?
If you answered "yes" to any of the above questions, please provide any additional information you may have, including the names of other individuals who may have information concerning this applicant.
10. Are the dates of privileges provided by the applicant on the top portion of this form accurate?
11.If not, please provide the correct dates: Beginning month _____ / year ____Ending month _____ / year _______
Evaluating Physicians Name:
Signature
Date:
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