Blank L For Texas Medical Board PDF Form Get L For Texas Medical Board Here

Blank L For Texas Medical Board PDF Form

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.

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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.

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FORM L
Form L Physician Licensure Evaluation Version 01.2026
Physician Licensure Evaluation – Texas Medical Board
Verification of Postgraduate Training and Professional Evaluation
APPLICANT: Complete the information in this box.
Full, Admin, Conceded Eminence, or Physician-in-Training Applicants: 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.
Provisional License or Physician Graduate Applicants: You must have evaluations from every facility with which you
have been affiliated in the past 2 years. Note – your licensure analyst may require additional evaluations outside the past 2
years.
Applicant’s Current Full Name: ____________________ Applicant TMB ID# _________________
Applicant’s Date of Birth: ____________________
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 Other: ___________
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 888-550-7516. Fax
submitted by the applicant and/or without the appropriate coversheet cannot be accepted.
▪ By email - Evaluator must submit the form from an official practice/institution email address to screen-
[email protected]. Emails sent from the applicant cannot be accepted. Only files attached as .pdf or .tif can be safely
opened and drop boxes, secured emails, encrypted messages, or links to outside sites cannot be accepted.
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 on page 2 and the Verification
of Professional History on page 3 are required.
FOR NON-TRAINING POSITIONS – Only completion of the Verification of Professional History on page 3 is required.
FORM L
Form L Physician Licensure Evaluation Version 01.2026
Applicant's Name___________________________________________ Page 2
Printed
UNUSUAL
CIRCUMSTANCES:
(For training
positions only)
Yes No 1. Did this individual ever take a leave of absence or break from training?
Yes No 2. Did this individual resign from training?
Yes No 3. Were any limitations or special requirements placed upon this individual for
professionalism or behavioral issues?
Yes No 4. Did this individual ever receive a written warning or documented counseling
about his/her behavior?
Yes No 5. Was this individual ever placed on probation for any reason?
Yes No 6. Is this individual currently under investigation?
Yes No 7. Were this individual’s privileges or duties ever reduced, suspended, or
revoked?
Yes No 8. Did this individual experience delayed promotion or delayed advancement to
the next level?
Yes No 9. Was this individual informed his/her contract would not be renewed?
Yes No 10. Was this individual suspended, terminated, or dismissed from training?
If you answered "yes" to any of the above questions, please provide any additional information you
may have.
VERIFICATION OF POST GRADUATE TRAINING
Only post-graduate training completed at this institution should be evaluated in this section.
POST GRADUATE TRAINING
PROGRAM PARTICIPATION:
Report incomplete postgraduate years
(PGY) separately from those that were
successfully completed.
If the postgraduate year is currently in
progress, report the expected completion
date in the “To” field.
PGY: _______
___ Internship
___ Residency
___ Fellowship
___ Research
PGY: _______
___ Internship
___ Residency
___ Fellowship
___ Research
PGY: _______
___ Internship
___ Residency
___ Fellowship
___ Research
PGY: _______
___ Internship
___ Residency
___ Fellowship
___ Research
FORM L
Form L Physician Licensure Evaluation Version 01.2026
Applicant's Name___________________________________________ Page 3
VERIFICATION OF PROFESSIONAL HISTORY
1. This evaluation is based on Personal Knowledge Review of Credential File
2. Is this applicant related to you? Yes No
3. Do you consider the applicant:
(a) Reliable? Yes No
(b) Ethical? Yes No
(c) Of good character? Yes No
4. Please rate the applicant:
Excellent
Good
Average
Poor
(a) Professional ability
(b) Attention to duties
(c) Breadth of education
(d) Interpersonal skills
5. Has applicant, to your knowledge, ever been guilty of:
(a) Fraud or dishonesty? Yes No
(b) Unprofessional conduct? Yes No
6. To your knowledge, has the applicant ever:
(a) been warned, censured, reprimanded, disciplined, had admissions monitored or privileges limited
or suspended? Yes No
(b) had disciplinary action taken against him/her by a licensing agency? Yes No
(c) been denied or surrendered a federal or state controlled substance permit? Yes No
(d) been arrested, fined, charged with or convicted of a crime, indicted, imprisoned
or placed on probation? Yes No
(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? Yes No
(f) been placed on probation, asked to withdraw, or reprimanded? Yes No
(g) been terminated, resigned in lieu of termination or during investigation? Yes No
If you answered "yes" to any of Question 5 and/or 6, please provide any additional information you may have, including
the names of other individuals who may have information concerning this applicant.
7. Provide dates of affiliation: Beginning month ______ / year _______ Ending month _______ / year _______
Evaluating Physician’s Name/Degree:
Title: Chief of Staff Department Chair Medical Director Training Director
Phone: Fax:
Address:
Email Address:
Signature: Date:
⇓ L For Texas Medical Board PDF

Document Specs

Fact Name Description
Purpose of Form L This form is used by the Texas Medical Board to evaluate the postgraduate training and professional history of applicants seeking physician licensure in Texas.
Applicant Requirements Applicants must provide evaluations from every facility they have been affiliated with over the past five years. Additional evaluations may be requested by the licensure analyst.
Evaluating Physician The evaluation must be completed by a physician in a senior position, such as Chief of Staff or Medical Director. Standard letters of recommendation are not acceptable.
Submission Methods The completed form can be submitted via mail, fax, or email. Each method has specific requirements to ensure acceptance by the Texas Medical Board.
Governing Laws The use of this form is governed by §164.007(c) and Chapter 160.010 of the Texas Medical Practice Act, which outlines confidentiality and immunity from civil liability.
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