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Blank L For Texas Medical Board PDF Template

The L For Texas Medical Board form is a critical document used for the evaluation of physicians seeking licensure in Texas. This form verifies postgraduate training and professional history, requiring detailed information from both the applicant and an evaluating physician. It ensures that the Texas Medical Board has the necessary information to assess the applicant's qualifications and suitability for practicing medicine.

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Open Form

Contents

Form Example

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 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
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

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Common mistakes

Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure every section is completed, including your full name and contact details.
Incorrect Dates: Providing wrong dates of affiliation or training can cause complications. Double-check the accuracy of all date entries.
Missing Evaluations: Not obtaining evaluations from all relevant facilities within the past five years is a common oversight. Collect evaluations from every institution you were affiliated with.
Signature Issues: Forgetting to sign the form can result in rejection. Make sure to sign where indicated.
Authorization Gaps: Not properly authorizing the release of information may hinder the evaluation process. Ensure all necessary authorizations are clearly stated.
Improper Submission Method: Submitting the form via an incorrect method (like personal email instead of institutional email) can lead to rejection. Follow the submission guidelines closely.
Ignoring Special Circumstances: Failing to disclose any unusual circumstances or limitations during training can raise red flags. Be transparent about any issues.
Neglecting Follow-Up: Not following up after submission can delay your application. Check the status of your application to ensure everything is in order.

Key takeaways

When filling out and using the L For Texas Medical Board form, keep these key takeaways in mind:

Complete Information: Ensure that all sections of the form are filled out completely. This includes your current name, date of birth, and TMB ID number.
Evaluation Requirement: You must obtain evaluations from every facility where you have worked in the past five years. Be aware that the licensure analyst may ask for additional evaluations beyond this timeframe.
Authorized Release: You will need to authorize various institutions and individuals to release information about your medical competence and professional conduct to the Texas Medical Board.
Evaluating Physician's Role: The evaluation must be completed by a physician in a specific role, such as Chief of Staff or Medical Director. Other forms of recommendation will not be accepted.
Submission Methods: The completed evaluation can be sent via mail, fax, or email. Each method has specific requirements, such as using an official hospital email address or including a cover sheet for fax submissions.
Confidentiality: Remember that all information provided in this form is confidential, but a copy may be shared with you if your application is reviewed by the Licensure Committee.

⇓ L For Texas Medical Board PDF

Steps to Using L For Texas Medical Board

Completing the L Form for the Texas Medical Board is an essential step in the licensure process for physicians. This form requires detailed information about your postgraduate training and professional history. Follow these steps carefully to ensure that all necessary information is provided accurately.

Begin by filling out the applicant section at the top of the form. Include your current full name, name at the time of affiliation (if different), date of birth, TMB ID number, address, telephone number, and email address.
Provide the name and address of the evaluating hospital or institution where you were affiliated.
Indicate the dates of your affiliation by specifying the start and end dates in the format mm/yy.
Fill in the department of affiliation and your position at the time of affiliation (choose from Intern, Resident, Fellow, Faculty, or Staff).
Sign the authorization statement, allowing all relevant parties to release necessary information to the Texas Medical Board.
For the evaluating physician section, have a qualified physician (Chief of Staff, Department Chairman, Medical Director, or Training Director) complete their part of the form. They must provide their title, name and degree, printed title, phone number, address, fax number, email address, and license number and state of licensure.
Complete the Verification of Postgraduate Training section if applicable. This includes detailing internship, residency, or fellowship experiences, along with any unusual circumstances that may have occurred.
Fill out the Verification of Professional History section. Answer questions regarding your relationship with the applicant, their professional conduct, and any disciplinary actions.
Ensure all information is accurate and that the evaluating physician signs and dates the form.
Submit the completed form directly to the Texas Medical Board via mail, fax, or email, following the specified submission guidelines.