Fillable License Information & Checklist Application for a Physician (California)

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License Information & Checklist Application for a Physician (California)

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Medical Board of California
Application for a Physician and Surgeon
License Information & Checklist
Licensing Program
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815-5401
Phone: (916) 263-2382
Fax: (916) 263-2487
www.mbc.ca.gov
MINIMUM REQUIREMENTS
Applicants must have received all of their medical school education from and graduated from a:
1)
U.S. or Canadian medical school accredited by the Liaison Committee for Medical Education (LCME),
the Committee on Accreditation of Canadian Medical Schools, or the Commission on Osteopathic
College Accreditation. http://lcme.org/directory/accredited-u-s-programs/
- OR -
2)
A foreign medical school which has been evaluated by the Educational Commission for Foreign Medical
Graduates (ECFMG) or one of the ECFMG authorized foreign medical school accreditation agencies and
deemed to meet the minimum requirements substantially equivalent to the requirements of medical
schools accredited by the Liaison Committee on Medical Education, the Committee on Accreditation of
Canadian Medical Schools, or the Commission on
Osteopathic College Accreditation.
The foreign medical school is listed on the World Federation for Medical Education (WFME) and the
Foundation for Advancement of International Medical Education and Research (FAIMER) World
Directory of Medical Schools join
t directory, or the World Directory of Medical Schools.
https://search.wdoms.org/
- OR -
3)
A foreign medical school that has been approved by the Medical Board of California (Board).
http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx
Disclosure of a United States Social Security Number (SSN) or an Individual Taxpayer Identification Number
(ITIN) is mandatory prior to the issuance of a
license
. Section 30 of the Business and Professions Code
authorizes collection of an SSN or ITIN. Section 31(e) of the Business and Professions Code allows the
State Board of Equalization and the Franchise Tax Board to share taxpayer information with the Board.
To meet the examination requirement, the applicant must have taken and passed all steps of the United
States Medical Licensing Examination (USMLE) or other acceptable examinations per Title 16 of the
California Code of Regulations
(CCR)
section 1328. Please refer to our website to obtain a copy of section
1328 for a listing of all acceptable ex
aminations.
Certification by the Educational Co
mmission
for Foreign Medical Graduates (ECFMG) is required if the
applicant graduated from an international medical school. To obtain further information regarding ECFMG
Certification, please refer to
their website at http://www.ecfmg.org/.
To meet the postgraduate training requirement, an applicant must have successfully completed a minimum
of 36 months of Accreditation Council for Graduate Medical Education (ACGME), Royal College of
Physicians and Surgeons of Canada (RCPSC) and/or The College of Family Physicians of Canada (CFPC)
accredited postgraduate training (ACGME approved training must be completed in the United States or it’s
territories, and RCPSC approved training must be completed in Canada) that includes at least four months
of postgraduate training in general medicine. The three years of postgraduate training must consist of at
least 24
-continuous months of training within the same program.
An applicant who has completed at least 36 months of board
-approved postgraduate training,
not less than
24 months of which was completed as a resident after receiving a medical degree from a combined dental
and medical degree program accredited by the Commission on Dental Accreditation (CODA) or approved
by the board, shall be eligible for lic
ensure.
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs PTL App Info (Rev 06/20)
GENERAL INFORMATION
Fingerprints: Applicants who reside in California must complete the electronic Live Scan fingerprint
process. The Request for Live Scan Service form may be obtained from the Board’s website. Please refer
to the following website for Live Scan facilities in California:
https://oag.ca.gov/fingerprints/locations.
Applicants residing outside California must submit two completed fingerprint cards or if visiting California,
you may have your fingerprints completed electronically at a California Live Scan facility.
Criminal Records Check from both the California Department of Justice and the Federal Bureau of
Investigation must be received prior to the issuance of a
Physician and Surgeon’s License.
Grounds for Denial: Each applicant’s credentials for licensure in California are reviewed on an individual
basis. The Board has the authority to deny licensure based upon an applicant’s act of dishonesty,
unprofessional conduct, conviction of a crime, discipline by a Licensing Board in or outside of California, or
inability to practice medicine safely.
The Federation Credentials Verification Service (FCVS): The FCVS is operated by the Federation of
State Medical Boards. The Board offers this link to FCVS as a convenience to applicants. Individuals may
learn more about FCVS at
https://www.fsmb.org/fcvs/.
The Board does not mandate the use the FCVS.
FCVS is NOT a requirement f
or filing a physician’s and
surgeon’s application. Applicants will be required to complete the Board’s application and provide all necessary
supporting documentation. As part of the application, applicants may request FCVS to submit their Medical
Professional Information Profile directly to the Board. The Board will review the information provided along with
the application and determine on an individual basis the items that will be accepted from FCVS.
NotaryCam:
NotaryCam is a company that provides an online notary service that is valid in California
and
may be used on the Board’s a
pplication forms. The Board does not mandate the use of
this online service.
The Board is providing this information as a convenience to applicants. Applicants may obtain further
information regardin
g this online notary service at https://www.notarycam.com/.
Certified Electronic Diploma (CeDiploma®):
CeCredential
Trust® is a company that provides an
alternative to a paper diploma and is accepted by the Board.
The Board does not
mandate that applicants
use this online service.
If a CeDiploma®
was not issued by the medical school, please contact the school
directly. The Board is providing this information as a convenience to applicants. Applicants may obtain
further information regarding this electronic diploma service at
https://www.cecredentialtrust.com/.
Previously Licensed in California: In accordance with California Business and Professions Code section
2428, a physician wh
ose California physician’s and s
urgeon’s license expired five or more years ago must
reapply for licensure. If you voluntarily canceled your license, you must reapply regardless of the time period.
Although
section 2428 allows you to undertake a re-
application process that is significantly streamlined, you
must meet all of the requirements as if you were applying for licensure for the first time. Upon receipt of your
application and fees, the Board will retrieve your previously imaged licensing record and determine what
documents may be used to meet the current requirements. In the event our imaged records do not contain
all of the
documents that are currently required, you may be requested to submit additional documents.
To meet the current licensing requirements, you must have completed at least three years of ACGME,
RCPSC, or CFPC accredited postgraduate training or meet all of the requirements under Business and
Professions Code section 2135.
You may not apply online if you have been previously licensed, you must submit a paper application with the
required fees. In addition, you must return your original California wall certificate. If it has been lost or
destroyed, you must submit a notarized statement indicating the reason you are unable to return the original.
Application Information for a Physician and Surgeon License – Page 2
GENERAL INFORMATION (Continued)
Limited Practice License: In addition to the application, supporting documents, and fees to obtain a
physician’s and surgeon’s license, it will be necessary to subm
it the Limited Practice License (LPL) form
, to
elect to apply for the limited practice license. This form is to advise the Board that you wish to apply for the
limited practice license and consent to sign an agreement to abide by the practice limitations indicated in the
independent clinical evaluation and any further conditions or terms set forth by the Board. The form is located
on the Board’s website and should be submitted with the application.
A clinical evaluation must be performed by a physician who specializes in the diagnosis and/or treatment
of disabilities of the same nature as your disability and is
familiar with your area of medical practice.
The reviewing physician must have a current valid California license with no history of discipline. The
reviewing physician must not have any personal, professional, business, or social relationship with you.
Per Title 16 of the CCR section 1315.55, the reviewing physician must include the following contents in the
clinical evaluation:
(1)
Be on the reviewing physician’s letterhead, dated, and signed under penalty of perjury, and shall contain
the original signature of the reviewing physician.
(2) Describe how the reviewer meets the criteria set forth in section 1315.53.
(3)
Include the applicant’s name and the diagnosis or description of the applicant’s disability.
(4) Describe all recommended practice
limitations and how those limitations permit the applicant to practice
medicine safely.
(5)
Provide suggested intervals between evaluations, if the disability is caused by a disease that will
progress or fluctuate in severity.
(6) Indicate whether the
evaluation included a review of the applicant’s medical records related to the
disability.
(7)
Describe the current treatment protocol and the applicant’s compliance with that treatment protocol, if
appropriate for the type of disability.
The evaluation shall have occurred not more than sixty (60) days from the date on which the application
was filed with the board.
APPLICATION CHECKLIST
Listed below are the minimum application and supporting materials required for a U.S. or Canadian
medical school graduate to obtain a physician’s and surgeon’s license. This list is not all-inclusive as
additional items may be necessary based on responses provided on the Application or information
obtained from other entities.
Application, Fees, and Fingerprints
Application For
Physician’s and
All six pages must be submitted together.
Surgeon’s License,
Forms L1A-L1F
Application Fee - $491.00
The application fee includes the required fingerprint processing fee. The
Initial License Fee or
The initial license fee is $808.00. Applicants may be eligible for the reduced
Reduced Initial License
Fee
program. Completion of the Current Postgraduate Trai
(CTV) form is required.
The license fee includes a mandatory $25 fee for the Steven M. Thompson
Physician Corps Loan Repayment Program
California by authorizing a plan for repayment of their educational loans, up
to $105,000, in exchange for their service in a designated underserved area
for a minimum of three years.
Application Information for a Physician and Surgeon License – Page 3
APPLICATION CHECKLIST (Continued)
Application, Fees, and Fingerprints
(Continued)
SONG-BROWN FAMILY
PHYSICIAN TRAINING
ACT
Voluntary Fee - $25.00
Minimum
You may voluntarily contribute any amount (minimum $25.00) to the Song-
Brown Health Care Workforce Training Act (Song-Brown Program). The
Statewide Health Planning and Development (OSHPD). The Song-Brown
Program was established to increase the number of family physicians to
provide needed medical services to the people of California. The program
encourages universities and primary care health professionals to provide
health care in medically underserved areas, and provides financial support
programs; and family nurse practitioner, physician assistant, and registered
nurse education programs throughout California. For further information
regarding the program, please visit the OSHPD website at:
https://oshpd.ca.gov/loans-scholarships-grants/grants/song-brown/.
Fingerprints:
Live Scan Form (CA Only)
- OR -
Two (2) Fingerprint Cards
Applicants who reside in California must complete the electronic Live Scan
fingerprint process. They will need to use the Request for Live Scan Service
form that may be obtained from the Board’s website. Mail a copy of the
completed form with the Application.
Applicants residing outside of
fingerprint cards or have fingerprints completed at a California Live Scan
application and appropriate processing fees.
completion.
Criminal Records Check from both the California Department of Justice and
the Federal Bureau of Investigation must be received prior to the issuance
of a physician’s and surgeon’s license.
Examination Documentation
ECFMG Certification
Status Report:
(International Medical website at
http://www.ecfmg.org/.
School Graduates Only)
Certification Status Report directly to the Board to be acceptable.
Official Examination
Scores from the
appropriate
examination entity:
USMLE, Federation of
Licensing Examiners (FLEX),
National Board of Medical
Examiners (NBME),
Licentiate of the Medical
Council of Canada (LMCC)
and State Board Exams
Official examination history reports must be requested from the appropriate
examination agency. Official examination history reports may be requested
from the following websites:
USMLE - https://www.fsmb.org/transcripts/
(Only an electronic submission will
be accepted by the Board.)
NBME - https://www.nbme.org/
LMCC - http://www.mcc.ca/
examination history report directly to the Board to be acceptable.
Application Information for a Physician and Surgeon License – Page 4
APPLICATION CHECKLIST (Continued)
Medical Education Documentation
Certificate of Medical
Education, Form MED
Official Medical School
Transcript
Certified Copy of Medical
School Diploma
A Certificate of Medical Education (Form MED)
medical school attended. Complete the applicant information at the top of
official medical
require completion of a new form. The form must be submitted directly
from the medical school to the Board to be acceptable.
letterhead affixed with the signature of the dean or registrar and the medical
completed during the medical curriculum is required. A transcript is required
from each medical school attended. The transcript must be submitted
directly from the medical school to the Board to be acceptable.
A certified copy of the medical school diploma is required. The certified
copy must have the original signature of the dean or registrar of the medical
statement attesting that the co
If applicable, a CeDiploma® will be accepted by the Board. The certified
copy of the diploma must be submitted
school to the Board to be acceptable.
Certified English
Certified English translations are required for all academic documents that
Translations (if applicable)
website for details regarding acceptable English translations. The certified
translation must be submitted directly to the Board to be acceptable.
Certificate of Completion
of ACGME/RCPSC/CFPC
Postgraduate Training,
Form PTA-PTB
Postgraduate Training Documentation
Training (Form PTA-PTB) is required to verify the completion of each year
of accredited training. The form may not be signed and dated prior to the
last day of the training year that will be used to meet the three years of
ACGME, RCPSC, or CFPC accredited postgraduate training required for
program must submit a PTA-PTB form to verify years of training.
A form
completion. The current program director must provide all of the required
information and responses on the form, sign and date the form, and affix
the program seal. If a program seal is not available, the program director
A “yes” response to any of the questions on Form PTA requires a signed
and dated letter of explanation from the current program director. The
completed form must be submitted directly from the program to the
Board to be acceptable. Any letters of explanation must be provided
on program letterhead, signed by the program director and submitted
directly to the Board.
Application Information for a Physician and Surgeon License – Page 5
APPLICATION CHECKLIST (Continued)
Postgraduate Training Documentation
(Continued)
Current Postgraduate
Training Verification,
Form CTV
License Verification
(if applicable)
If an applicant is currently enrolled in an accredited training program when
paying the initial licensing fee, this form is necessary to be eligible for the
reduced initial licensing fee. Complete the top section and submit the form
to the current training program for completion. The current program director
must provide all of the required information and responses on the form, sign
and date the form, and affix with the program seal. If a program seal is not
available, the program director must sign in the presence of a notary and
the notary seal must be affixed. The completed form must be submitted
directly from the program to the Board to be acceptable.
Verification of Medical License(s)
License verification is required from each U.S. state, U.S. territory, or
Canadian province in which a license to practice medicine has been issued.
The official license verification must be submitted directly from the
licensing authority to the Board.
Other Items
Explanation For
Application Question:
Form EXP
This form may be used to provide a detailed written explanation for a “yes”
required for each question.
(If applicable)
Timeline of Activities,
Form TOA
A complete timeline from the graduation of medical school to the beginning
chronological description of all professional and non-professional activities
with no gaps.
If an applicant has completed any externships, observerships, or volunteer
activities in California, please include a detailed description of the duties
physician.
Submit the signed and dated Time
Board.
Application Information for a Physician and Surgeon License – Page 6
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Completed 20 December 2020

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