Instructions for completing the license application Read

Instructions For Completing The License Application Read-Free PDF

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Section One Demographics, 1 Print your legal name This is the name that will appear on your license certificate If you. have changed your name submit a copy of the associated legal document with this. application Print your current first name middle initial and last name on the copy of the. legal document, 2 Print any other name which may appear on documents you submit or others may submit. as part of this application i e maiden name legal name change etc If you have. changed your name submit a copy of the associated legal document with this. application Print your current first name middle initial and last name on the copy of the. legal document, 3 Print your current mailing address and contact information Your mailing address cannot be. a post office box unless you also enter your street address Application reviewers will. contact you via e mail and follow up in writing to your mailing address It is your. responsibility to notify the Board immediately in writing by mail or FAX of changes to your. mailing address You may also provide an Address of Record and home business addresses. attach to application The Address of Record will be printed on your license certificate If. you do not provide an Address of Record before becoming licensed your mailing address. will be printed on your license certificate Your name and address will be posted on the. Online License Directory As a matter of information under New Jersey public disclosure. law any of your license addresses must be provided if requested under the Open Public. Records Act, 4 Enter your date and place of birth Federal law limits the issuance or renewal of professional. licenses to U S citizens or qualified aliens To comply with federal law you must provide. evidence of citizenship status If you were born in the United States submit a copy of. your birth certificate or passport with this application If you were born elsewhere. submit a copy of your passport or a copy of an official document granting citizenship status. If you are not a U S citizen submit a copy of the official immigration document authorizing. you to work in the United States Questions about your immigration status and whether it is. a qualifying status under federal law should be directed to the U S C I S at 800 375. 5 Pursuant to N J S A 2A 17 56 44e of the New Jersey Child Support Enforcement Law. N J S A 54 50 25 of the New Jersey Taxation law and Section 1128E b 2 A of the Social. Security Act the Board is required to obtain your Social Security number The Board is. further obligated to provide your Social Security number to the Director of Taxation the. Probation Division or any other agency responsible for child support enforcement upon. request and to the National Practitioner Data Bank and the H I P Data Bank when. reporting adverse actions, Pursuant to the Federal Privacy Act 5 U S C Section 55a note b the Board is requesting.
your consent to use your Social Security number for the following purposes 1 to verify. identity 2 to aid in the collection of financial obligations due and owing the Board or any. other State agency and 3 to aid in the disclosure to State or federal law enforcement and. licensing officials and agencies of information obtained in investigations pertaining to. licensure and disciplinary proceedings, 6 Circle Yes or No If Yes enter the type of license registration for which you applied and. the date you applied month year,Section Two Education. Pre Medical Education,Answer the questions by circling yes or no. Print the information requested for each college university you attended Enter the dates in the. following format From Month Year To Month Year,Medical Education. List every medical school in which you were ever enrolled EVEN IF NO CREDIT WAS. GRANTED OR NO CREDIT WAS SOUGHT FOR THE STUDY Enter your full name at the top. of form BME MEV and mail a copy of the form to every school you attended not just the. school from which you graduated Direct the school s to return the form with an official. transcript directly to the N J B M E address on the form Forms submitted by you will not be. accepted they must be mailed directly from the school to the N J B M E. If submitting a copy of a foreign medical school diploma or transcript A copy of the. original diploma must be notarized Transcripts and diplomas which are not in English must be. translated by one of the approved translation agencies Appendix A If a translated copy is not. received the foreign language copy will be returned to you for translation. Graduates of foreign medical schools must be certified by the Educational Commission for. Foreign Medical Graduates E C F M G Contact the E C F M G see Appendix A and request that. your certification be sent directly to the N J B M E. Applicants educated in India Pakistan or Bangladesh submit an original and official Mark. Sheet for each Bachelor of Science and or Bachelor of Medicine M B B S Examination taken. Failed examinations must be included Submit the certificate verifying completion of a year of. compulsory rotating internship, Clinical Clerkships Circle Yes or No for each category.
Board Certifications Complete by entering the required information for each certification you. Endorsement Examinations Enter the dates for each exam taken Enter N A for exams not. taken If your application is based on a licensing examination taken in another state prior to. December 31 1972 complete Section 1 and mail Form BME VSL to the state medical board. which administered the exam Direct them to complete Sections 2 3 and 4 and return it directly. to the N J B M E at the address on the form This form is not to be used if you are applying on the. basis of FLEX Endorsement National Board Endorsement U S M L E Endorsement or N B O M E. COMLEX Endorsement State exams taken after December 31 1972 will not be accepted for. endorsement, If you are applying on the basis of FLEX Endorsement National Board Endorsement U S M L E. Endorsement or N B O M E COMLEX Endorsement contact the appropriate organization see. Appendix A and have your report sent directly to the N J B M E. Postgraduate Training, List each training program including Fifth Pathway Program internship residency and or fellowship. in which you have participated and the information requested on the form for each program Enter. your full name at the top of Form BME VPT and mail a copy of the form to each training program. you list whether you received credit no credit or partial credit Direct the training program to mail. the form directly to the N J B M E at the address on the form. Section Two Education continued, Graduates of L C M E A O A approved medical schools and graduates of foreign medical. schools who graduated prior to July 1 1985 must successfully complete at least one year of. A C G M E or A O A approved postgraduate training, Graduates of foreign medical schools who graduated after July 1 1985 and prior to July 1. 2003 must successfully complete a minimum of three 3 years of A C G M E or A O A. approved postgraduate training, All applicants who graduated from medical school after July 1 2003 must successfully.
complete a minimum of two 2 years of postgraduate training in an A C G M E or A O A. accredited program and have a signed contract for a third year of training in an accredited. program where at least two years of that training are in the same field or would when. considered together be credited toward the criteria for certification by a single specialty board. Section Three Employment Malpractice History Other Licenses. Privileges Affiliation Employment Appointments History. Print the required information for every private office residency program H M O etc where. you were employed or with whom you were affiliated for the five year period that immediately. precedes the filing of this application Enter your full name at the top of Form BME PEA and. mail a copy of the form to every entity you have listed in this section of your application. Malpractice History, Answer all of the questions Attach a written statement identifying every malpractice suit in. which you have been listed as a defendant Include the name of the plaintiff date of the. incident and status of each suit i e open dismissed closed with payment Provide your. personal description of the clinical aspects of the case as it would be explained to a fellow. professional and a copy of the Complaint or Bill of Particulars If the malpractice suit has been. closed you must provide a copy of the Final Disposition including the amount of payment on. your behalf Failure to provide this information when submitting your application will delay. your application review If a malpractice carrier has taken an action with reference to. you or your policy you must submit an explanation and documentation of the action. from the carrier, Enter your full name at the top of Form BME MI and forward a copy of the form to every. malpractice insurance carrier which has provided coverage to you during the three year period. immediately preceding the submission of your license application If your malpractice coverage. is was provided by a hospital forward the form to the Risk Management office of the hospital. Direct the hospital and insurance carriers to mail the form directly to the N J B M E forms. submitted by you will not be accepted,Verification of State License. Print the required information for each license and or permit ever held in another state For. each license or permit held no matter the status complete Section 1 of Form BME VSL and. mail the form to the state which granted it Direct them to complete Section 2 and 4 and mail. it directly to the N J B M E, N ote All applicants meeting the Postgraduate Training criteria detailed in Section Two of. these instructions who have never held a plenary medical license in any other state or. jurisdiction are not required to submit forms BME PEA BME MI and BME VSL. Section Four Character Ethics and Medical Conditions. Information regarding moral character and ethical professional responsibility. Answer all questions by circling either Yes or No For all Yes answers attach a full. explanation and any pertinent documentation Print your first name middle initial and last. name on each page of any attachment, Question a asks about any arrests charges or offenses you may have committed Carefully.
review the following definitions and instructions before answering the question. Definitions for the purpose of this question, Arrest includes any detaining holding or taking into custody by any police or other law. enforcement authorities to answer for the alleged performance of any offense. Charge includes any indictment complaint information summons or other notice of the. alleged commission of any offense, Offense includes all felonies crimes high misdemeanors misdemeanors disorderly persons. offenses petty disorderly offenses driving while intoxicated impaired motor vehicle offenses. violations of probation or any other court order and local ordinance violations. Instructions for the purpose of question a Answer Yes and provide all information to the. best of your ability EVEN IF,1 You did not commit the offense charged. 2 The charges were dismissed or subsequently downgraded to a lesser charge. 3 You completed a Pretrial Intervention P T I or equivalent diversionary program. 4 You were not convicted,5 You did not serve any time in prison or jail or. 6 The charges or offenses happened a long time ago. Answer No IF, 1 You have never been arrested or charged with any crime or offense or.
2 The records relating to a charge an arrest or conviction have been expunged by the court. or a government agency, Questions h through k Under N J S A 2A 17 56 44d an answer of Yes to any of questions. h a h b i j k will result in a denial of licensure Furthermore any false certification of. these questions may subject you to a penalty including but not limited to immediate. revocation or suspension of licensure,Medical Conditions Chemical Substances. Answer all questions by circling Yes No or Not Applicable N A unless you are asserting. your Fifth Amendment Privilege against self incrimination If you are asserting your Fifth. Amendment Privilege write that in the space under the first paragraph on the page. If you are answering the questions attach a detailed explanation for answers of Yes and. include your printed first name middle initial and last name on each page of the attachment. Section Four Character Ethics and Medical Conditions continued. For the purposes of these questions the following phrases or words have the following. Ability to practice medicine is to be construed to include all of the following. 1 The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned. medical judgments and to learn and keep abreast of medical developments and. 2 The ability to communicate those judgments and medical information to patients and other. health care providers with or without the use of aids or devices such as voice amplifiers. 3 The physical capability to perform medical tasks with or without the use of aids or devices. such as corrective lenses or hearing aids, Medical condition includes physiological mental or psychological conditions or disorders such. as but not limited to orthopedic visual speech and hearing impairments cerebral palsy. epilepsy muscular dystrophy multiple sclerosis cancer he. for a New Jersey Medical License Read the application and instructions before completing the application Each section of the application is explained in these instructions follow them carefully Completing the enclosed application and mailing it to the Board office does not constitute the completion of your application You must request

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