Florida

Board

of

Medicine

Applicants who answer “Yes” to any of the Health History questions on the application are required to submit the following documentation to the board office:

Self-Explanation – Applicants must submit a letter in your own words explaining the medical condition(s) or occurrence(s). Include a description of all treatments and diagnoses you have received for any condition(s)/impairment(s) you are/have been treated for. Include all medications prescribed and all physicians/counselors that have provided treatment.

Physician(s) Letter – Applicants must submit a statement from your treating physician(s)/counselor(s) for each condition you are/were being treated for and whether or not you are currently able to safely practice Medicine. The physician’s statement should include all DSM IIIR/ DSM IV, Axis I, II, and III diagnoses.

Applicants who have ever been denied licensure, had disciplinary action taken against their license, or have action pending against their license to practice any health care related profession by a licensing authority are required to submit the following documentation to the board:

Self-Explanation – Applicants who have listed disciplinary action on the application must submit a letter in your own words describing the circumstances of the action.

Agency Records – All relevant documentation regarding the action should be sent to the board office by the licensing agency. If the records are not available, you must have a letter on agency letterhead sent from the licensing agency attesting to their unavailability.

Any applicant who has ever been found guilty of or pled guilty or no contest/nolo contendere to any charge other than a minor traffic offense must list each offense on the application. Failure to disclose criminal history may result in denial of your application. Each application is reviewed on its own merits.

The Board of Medicine has created guidelines for specific offenses to be cleared in the board office; however, staff cannot make determinations in advance as laws and rules do change over time. Violent crimes and repeat offenders are required to be presented to the Board of Medicine for review. Evidence of rehabilitation is important to the board members when making licensure decisions.

Applicants with prior criminal convictions are required to submit the following documentation to the board:

Self-Explanation – Applicants who have listed offenses on the application must submit a letter in your own words describing the circumstances of the offense.

Final Dispositions/Arrest Records – Final disposition records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the clerk of the court attesting to their unavailability.

Completion of Probation/Parole/Sanctions – Probation and financial sanction records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. Parole records for offenses can be obtained from the Department of Corrections or at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the clerk of the court attesting to their unavailability.

Effective July 1, 2012, Section 456.0635, Florida Statutes (F.S.), provides that health care boards or the department shall refuse to issue a license, certificate or registration and shall refuse to admit a candidate for examination if the applicant:

1. Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, F.S., (relating to social and economic assistance), Chapter 817, F.S., (relating to fraudulent practices), Chapter 893, F.S., (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction unless the candidate or applicant has successfully completed a drug court program for that felony and provides proof that the plea has been withdrawn or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, or registration, unless the sentence and any subsequent period of probation for such conviction or plea ended:
   1. For the felonies of the first or second degree, more than 15 years from the date of the plea, sentence and completion of any subsequent probation;
   2. For the felonies of the third degree, more than 10 years from the date of the plea, sentence and completion of any subsequent probation;
   3. For the felonies of the third degree under section 893.13(6)(a), F.S., more than five years from the date of the plea, sentence and completion of any subsequent probation;
2. Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues), unless the sentence and any subsequent period of probation for such conviction or pleas ended more than 15 years prior to the date of the application;
3. Has been terminated for cause from the Florida Medicaid program pursuant to section 409.913, F.S., unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent five years;
4. Has been terminated for cause, pursuant to the appeals procedures established by the state or Federal Government, from any other state Medicaid program, unless the candidate or applicant has been in good standing with a state Medicaid program for the most recent five years and the termination occurred at least 20 years before the date of the application;
5. Is currently listed on the United States Department of Health and Human Services Office of Inspector General’s List of Excluded Individuals and Entities.

Effective January 1, 2013, applicants for initial licensure must use a LiveScan service provider to submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to applicant. The results of the search will be returned to the Care Provider Background Screening Clearinghouse and made available to the Department for consideration during the licensure process. The fingerprints submitted by the applicant will be retained by FDLE and the Clearinghouse. All costs for conducting a criminal history background screening are borne by the applicant.

It is important to use the correct Originating Agency Identification (ORI) when submitting fingerprints. If you do not provide an ORI number or if you provide an incorrect ORI number to the service provider, the board office will not receive your fingerprint results, so it is extremely important to use the correct ORI when having your fingerprints scanned.

Applicants can use any FDLE approved LiveScan service provider to submit their fingerprints. The applicant is fully responsible for selecting the service provider and ensuring the results are reported to the Department.  If you are applying for initial licensure after December 15, 2012, You must print this form and take it with you to a Livescan service provider. For more information, FAQs, and a list of all approved Livescan service providers please visit the Department’s website at: https://www.flhealthsource.gov/background-screening and click on the Livescan Service Providers tab.