Florida

Board

of

Medicine

If a “Yes” response was provided to any of the health history questions on your application for licensure, provide the following documents:

A letter from a Licensed Health Care Practitioner, who is qualified by skill and training to address the condition identified, which explains the impact the condition may have on the ability to practice the profession with reasonable skill and safety. The letter must specify that the applicant is safe to practice the profession without restrictions or specifically indicate the restrictions that are necessary. Documentation provided must be dated within one year of the application date.

A written self-explanation, identifying the medical condition(s) or occurrence(s); and current status.

If you have ever been denied a license, had disciplinary action taken against a license, or have had other action taken against you by a licensing agency, you will need to submit the following for each denial and action:

• Written self-explanation describing in detail the circumstances surrounding the circumstances of the action.
• Agency records of that action, including all administrative complaints and final orders.

If you are currently under investigation or prosecution in any jurisdiction for an act that would constitute a violation under section 456.072, Florida Statutes or section 458.331, Florida Statutes, please submit the following:

• Written self-explanation describing in detail the circumstances surrounding the investigation or prosecution.
• A letter from the state board/entity explaining the results of the investigation or prosecution.

Failure to disclose disciplinary history on your application may result in the denial of your application for licensure.

All actions are reviewed by the Chair of the Council on Physician Assistants to determine whether a personal appearance is required at a council meeting. If you are required to appear, you will be notified in writing by Board staff within 30 days of the scheduled meeting.

If you have ever been found guilty of or had adjudication withheld for, or pled guilty or nolo contendere (no contest) to a crime in any jurisdiction other than a minor traffic offense, submit the following for each conviction:

• Written self-explanation describing in detail the circumstances surrounding the arrest and conviction.
• Arrest records from the arresting jurisdiction.
• Final disposition of the case.
• Documents showing completion of sentence (probation, parole, sanctions, fines, etc.).

If arrest, disposition, or completion of sentencing records are unavailable, the clerk of courts or other agency responsible for those records may submit documentation attesting to the unavailability of those records.

Failure to disclose criminal history on your application that impacts the practice of medicine or your ability to practice medicine with reasonable skill and safety may result in the denial of your application for licensure.

Some criminal history may require a review by the Chair of the Council on Physician Assistants to determine whether a personal appearance is required at a council meeting. If you are required to appear, you will be notified in writing by Board staff within 30 days of the scheduled meeting.

Important Notice:  Applicants for licensure, certification, or registration and candidates for examination may be excluded from licensure, certification, or registration if their felony convictions fall into certain timeframes as established in section 456.0635(2), Florida Statutes.

If a “Yes” response was provided to any of the criminal and Medicaid/Medicare fraud questions on your application for licensure, provide the following documents:

• Written self-explanation for each question including the county and state of each termination or conviction, date of each termination or conviction, and copies of supporting documentation.
• Supporting documentation including court dispositions or agency orders where applicable.

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 the applicant. The results of the search will be returned to the Care Provider Background Screening Clearinghouse and made available to the Department of Health 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.

Please ensure that the Originating Agency Identification (ORI) number is provided to the Livescan service provider when you submit your fingerprints. If you do not provide an ORI number or if you provide an incorrect ORI number to the Livescan service provider, the Board office will not receive your fingerprint results. The applicant is fully responsible for selecting the Livescan service provider and ensuring submission of the prints to the Department of Health.

You can find an approved Livescan service provider at https://www.flhealthsource.gov/background-screening.

Please take this form with you to the Livescan service provider. Please check the Livescan service provider’s requirements to see if you need to bring any additional items. Also verify that the ORI number submitted by the Livescan service provider matches the information provided.