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Blank L For Texas Medical Board PDF Form

The L For Texas Medical Board form is essential for physicians seeking licensure in Texas. This form verifies postgraduate training and professional evaluations, requiring detailed information from both the applicant and evaluating physician. Completing this form accurately is crucial for a smooth application process, so be sure to fill it out by clicking the button below.

Article Guide

The L For Texas Medical Board form, also known as the Physician Licensure Evaluation, serves as a critical component in the process of obtaining a medical license in Texas. This form requires applicants to provide detailed information about their postgraduate training and professional history, ensuring a thorough evaluation of their qualifications. Applicants must complete specific sections, including personal identification details, such as their current full name, date of birth, and contact information. Furthermore, they must secure evaluations from every facility with which they have been affiliated in the past five years, although additional evaluations may be requested by the licensure analyst. The form also mandates that evaluating physicians, who hold designated positions such as Chief of Staff or Medical Director, complete a separate evaluation section. This section assesses the applicant’s professional conduct, reliability, and ethical standards. It is crucial for evaluating physicians to submit the completed form directly to the Texas Medical Board, adhering to strict submission guidelines. Confidentiality is emphasized throughout the process, protecting the sensitive information shared by both the applicant and the evaluating physician. The L For Texas Medical Board form is essential in ensuring that only qualified and competent individuals are granted the privilege to practice medicine in Texas.

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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	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 [email protected]. Emails sent from the applicant or from a non-agency email address cannot be accepted.

Title:	 Chief of Staff
Evaluating Physician’s	 Department Chairman
Evaluating Physician’s	 Medical Director
Name/Degree:	 Training Director

Printed

Title:

Phone:Address:

Fax:E-Mail:

Evaluating Physician's License Number and

State of Licensure

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 01.2020

FORM L

Applicant's Name___________________________________________	Page 2
Printed

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

Department:

date in the “To” field.

PGY: _______

___________________________________

Report Internships, Residencies and

___ Internship

From: ___/___/___

To: ___/___/___

Fellowships separately. Use one section

___ Residency

per department.

Credit received?

___ Fellowship

___ Research

Full

*Partial

in progress

*For partial credit– how many months?______

Department:

PGY: _______

___________________________________

___ Internship

From: ___/___/___

To: ___/___/___

___ Residency

Credit received?

___ Fellowship

___ Research

Full

*Partial

in progress

*For partial credit– how many months?______

UNUSUAL

 Yes  No

Did this individual ever take a leave of absence or break from training?

CIRCUMSTANCES:

 Yes  No

Did this individual resign from training?

(For training

 Yes  No

Were any limitations or special requirements placed upon this individual for

positions only)

professionalism or behavioral issues?

Please attach an

 Yes  No

Did this individual ever receive a written warning or documented counseling

about his/her behavior?

explanation for any

 Yes  No

Was this individual ever placed on probation for any reason?

“yes” response.

 Yes  No

Is this individual currently under investigation?

 Yes  No

Were this individual’s privileges or duties ever reduced, suspended, or

revoked?

 Yes  No

Did this individual experience delayed promotion or delayed advancement to

the next level?

 Yes  No

Was this individual informed his/her contract would not be renewed?

 Yes  No

10. Was this individual suspended, terminated, or dismissed from training?

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 01.2020

FORM L


Applicant's Name___________________________________________					Page 3

	VERIFICATION OF PROFESSIONAL HISTORY
1.		This evaluation is based on  Personal Knowledge	 Review of Credential File
2.		How long have you known the applicant? Years________ Months ________
3.		Is the applicant related to you?		 Yes	 No
4.		Do you know the applicant well?		 Yes	 No
5.		Has your acquaintance with the applicant continued until recent date?		 Yes	 No

6.Do you consider the applicant:

(a) Reliable?	 Yes	 No
(b) Ethical?	 Yes	 No
(c) Of good character?	 Yes	 No

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?	 Yes	 No
(b) Unprofessional conduct?	 Yes	 No

9.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 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?

 Yes

 No

11.If not, please provide the correct dates: Beginning month _____ / year ____Ending month _____ / year _______

Evaluating Physicians Name:

Printed

Signature

Date:

LICENSURE APPLICATION FORM L PHYSICIAN LICENSURE EVALUATION

Version 01.2020

➤ PDF File

Form Specifications

Fact Name	Details
Form Purpose	This form is used for evaluating a physician's postgraduate training and professional history.
Applicant Requirement	Applicants must provide evaluations from every facility they were affiliated with in the past five years.
Evaluating Physician	The evaluation must be completed by a Chief of Staff, Department Chairman, Medical Director, or Training Director.
Submission Methods	Evaluators can submit the form via mail, fax, or email, following specific guidelines for each method.
Confidentiality	All information on Form L is confidential under §164.007(c) of the Medical Practice Act.
Licensure Committee	The Texas Medical Board must provide a copy of this form to the applicant if their application is referred to the Licensure Committee.
Training Verification	For training positions, both Verification of Postgraduate Training and Verification of Professional History must be completed.
Unusual Circumstances	Evaluators must report any unusual circumstances related to the applicant's training, such as leaves of absence or disciplinary actions.
Governing Laws	This form is governed by the Texas Medical Practice Act, particularly Chapters 160 and 164.

L For Texas Medical Board: Usage Guidelines

Filling out the L For Texas Medical Board form requires careful attention to detail. Each section must be completed accurately to ensure a smooth evaluation process. Follow these steps to fill out the form correctly.

Begin with the Applicant Information section. Fill in your current full name and any previous name if applicable.
Provide your date of birth, Texas Medical Board ID number, address, telephone number, and email address.
In the Evaluating Hospital/Institution section, write the name and address of the institution where you were affiliated.
Indicate the dates of your affiliation by entering the start and end dates in the specified format (mm/yy).
Fill in the department of affiliation and your position at that time (Intern, Resident, Fellow, Faculty, or Staff).
Sign the authorization statement, allowing the release of your records to the Texas Medical Board.
For the Evaluating Physician section, ensure that a qualified physician completes the evaluation. This must be someone in a recognized position.
The evaluating physician must provide their title, name, degree, phone number, address, fax number, email, and license number.
In the Verification of Postgraduate Training section, complete the details regarding your postgraduate training, if applicable.
Answer all questions related to unusual circumstances, providing additional information if necessary.
In the Verification of Professional History section, the evaluating physician should answer questions regarding their knowledge of your professional conduct and history.
Finally, the evaluating physician should sign and date the form.

Once completed, ensure that the form is submitted according to the guidelines provided. This includes mailing, faxing, or emailing the form directly from the evaluating institution. Timely submission is crucial for your application process.

Your Questions, Answered

What is the purpose of the L For Texas Medical Board form?

The L For Texas Medical Board form is used to evaluate physicians seeking licensure in Texas. It verifies postgraduate training and professional history. This evaluation is essential for the Texas Medical Board to assess an applicant's qualifications and competence to practice medicine safely.

Who needs to complete this form?

The form must be completed by an evaluating physician who holds a significant position, such as Chief of Staff, Department Chairman, Medical Director, or Training Director at the applicant's affiliated institution. Letters of recommendation or other standard verification forms are not acceptable substitutes.

How should the completed form be submitted?

The completed form can be submitted in three ways: by mail, fax, or email. If mailing, the evaluator should place the form in an envelope, seal it, and sign over the flap before sending it to the Texas Medical Board. For fax submissions, the form must include an official coversheet from the institution. Email submissions must come from an official institutional email address, as those from personal addresses will not be accepted.

What information is required from the applicant?

Applicants must provide their full name, date of birth, Texas Medical Board ID number, address, telephone number, and email. They must also list the evaluating hospital or institution, the dates of their affiliation, and their position during that time. Additionally, applicants must authorize the release of their medical and educational records for evaluation.

What happens if the evaluating physician finds unusual circumstances?

If the evaluating physician identifies any unusual circumstances, such as leaves of absence, disciplinary actions, or behavioral issues, they must provide detailed explanations. This information is crucial for the Texas Medical Board to make informed decisions regarding the applicant's licensure.

Is the information provided on this form confidential?

Yes, the information on the L For Texas Medical Board form is confidential under the Medical Practice Act. However, if the application is referred to the Licensure Committee, the Board must provide a copy of the form and its attachments to the applicant for review.

Common mistakes

Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure every section is completed, including your full name, date of birth, and contact information.
Missing Evaluations: Not obtaining evaluations from all affiliated facilities in the past five years is a common oversight. Make sure to gather all necessary evaluations.
Incorrect Dates: Entering inaccurate dates for your affiliations can cause confusion. Double-check the start and end dates of your training and positions.
Signature Issues: Forgetting to sign the form or providing an incomplete signature may result in rejection. Always ensure your signature is present and clear.
Improper Submission: Submitting the form through the wrong channel, such as personal email or without the required coversheet, can lead to non-acceptance. Follow the submission guidelines carefully.
Failure to Authorize: Not properly authorizing the release of information can halt the process. Ensure you sign the authorization section to allow necessary information sharing.
Ignoring Special Circumstances: Not addressing any unusual circumstances in your training history can lead to misunderstandings. Provide explanations for any "yes" responses regarding issues in your training.

Documents used along the form

When applying for a medical license in Texas, the Form L for the Texas Medical Board is just one piece of the puzzle. Several other documents may be required to complete your application. Understanding these forms can help streamline the process and ensure that you meet all necessary requirements. Below is a list of common forms and documents that often accompany the Form L.

Application for Licensure: This is the primary document where you provide your personal information, education history, and details of your professional experience. It serves as the foundation for your licensure application.
Verification of Medical Education: This document confirms that you have completed the necessary medical education from an accredited institution. It typically requires your school to send official transcripts directly to the Texas Medical Board.
Criminal Background Check Authorization: As part of the licensing process, you must authorize a background check. This form allows the Texas Medical Board to obtain your criminal history, if any, from relevant authorities.
Verification of Postgraduate Training: Similar to the Form L, this document verifies your residency or fellowship training. It ensures that you have completed the required training in a recognized program.
Letters of Recommendation: While not always mandatory, letters from colleagues or supervisors can strengthen your application. These letters should speak to your professional abilities and character.
Proof of Exam Scores: You will need to submit evidence of passing scores from relevant medical licensing examinations, such as the USMLE or COMLEX. This document verifies your competency in medical knowledge.
Continuing Medical Education (CME) Certificates: If applicable, these certificates demonstrate that you have engaged in ongoing education to stay current in your field. This is often required for certain specialties.
Disclosure of Medical Malpractice History: If you have ever faced a malpractice claim, this document requires you to disclose that information. Transparency is crucial in the licensing process.

Gathering these documents can seem overwhelming, but taking it step by step can simplify the process. Each form plays a vital role in showcasing your qualifications and ensuring that you meet the standards set by the Texas Medical Board. Being well-prepared will help you move forward confidently in your journey to becoming a licensed physician in Texas.

Similar forms

Form A - Application for Physician Licensure: Similar to Form L, Form A requires personal and professional information from the applicant, including details about their education and training history. Both forms aim to assess the qualifications of the physician for licensure.
Form B - Verification of Medical Education: This document verifies the applicant's medical education. Like Form L, it requires confirmation from educational institutions about the applicant's training and qualifications.
Form C - Background Check Consent: Both Form C and Form L include sections that authorize the release of personal information for verification purposes. They ensure that the Texas Medical Board can conduct thorough background checks on applicants.
Form D - Professional References: Similar to Form L, Form D collects evaluations from colleagues and supervisors regarding the applicant's professional conduct and competence. Both forms emphasize the importance of professional evaluations in the licensure process.
Form E - Medical License Renewal Application: Form E, like Form L, requires detailed information about the physician's professional history. It assesses ongoing qualifications and any changes since the last licensure.
Form F - Continuing Medical Education (CME) Documentation: This form requires proof of ongoing education and training, similar to the postgraduate training verification in Form L. Both documents ensure that physicians maintain their competencies throughout their careers.

Dos and Don'ts

When filling out the L For Texas Medical Board form, it is essential to adhere to specific guidelines to ensure a smooth application process. Below are six recommendations for what to do and what to avoid.

Do: Provide accurate and complete information in all required fields.
Do: Ensure that all evaluations are from facilities affiliated with you in the last five years.
Do: Sign and date the form before submission to validate your application.
Do: Use the official email address of the evaluating hospital when submitting electronically.
Don't: Submit letters of recommendation in place of the required evaluation form.
Don't: Leave any sections blank; if a question does not apply, indicate that it is not applicable.

Misconceptions

There are several misconceptions surrounding the L For Texas Medical Board form that applicants and evaluators should be aware of. Understanding these can help ensure a smoother application process.

Misconception 1: Only recent evaluations are required.

Many believe that evaluations from the last year or two are sufficient. In reality, evaluations from every facility affiliated with the applicant in the past five years are necessary. Additionally, the licensure analyst may request evaluations older than five years.

Misconception 2: Letters of recommendation can replace the form.

Some applicants think that letters of recommendation will suffice. However, the form must be completed by a qualified physician holding specific positions, such as Chief of Staff or Medical Director. Standard letters will not be accepted.

Misconception 3: Submission methods are flexible.

There is a belief that any submission method is acceptable. In fact, the completed evaluation must be sent directly from the evaluating physician via mail, fax, or official email. Submissions from the applicant or unofficial addresses will not be accepted.

Misconception 4: All information is public.

Some think that all information on the form is public. While the form is confidential, a copy must be provided to the applicant if their application is referred to the Licensure Committee.

Misconception 5: Only training positions need extensive evaluations.

It's a common misunderstanding that only applicants for training positions require detailed evaluations. Non-training positions also necessitate the completion of the Verification of Professional History section.

Misconception 6: The form can be filled out casually.

Lastly, some applicants may think that the form can be filled out without careful consideration. Each question must be answered accurately and truthfully, as any discrepancies can lead to complications in the licensure process.

Key takeaways

When filling out and using the L For Texas Medical Board form, consider the following key takeaways:

Complete All Sections: Ensure that all sections of the form are filled out accurately, including applicant and evaluating physician information.
Five-Year Requirement: Evaluations are required from every facility affiliated with the applicant in the past five years.
Authorization: The applicant must authorize the release of information from various sources, including hospitals and government agencies.
Evaluating Physician's Role: The evaluation must be completed by specific positions such as Chief of Staff or Medical Director; letters of recommendation are not acceptable.
Submission Methods: The completed evaluation can be submitted via mail, fax, or email, following the specific guidelines provided.
Confidentiality: All information on the form is confidential but may be shared with the applicant if referred to the Licensure Committee.
Training vs. Non-Training: Different sections must be completed based on whether the applicant is in a training position or not.
Unusual Circumstances: Be prepared to provide explanations for any "yes" responses regarding unusual circumstances in the applicant's training history.
Professional History: Evaluators must base their assessments on personal knowledge or a review of the applicant’s credential file.
Accuracy of Dates: Confirm the accuracy of the dates provided by the applicant regarding their privileges.