HAR §16-85-7. Application

(a) An application for license by examination or by endorsement shall be made under oath on a form to be provided by the board. The form shall require the applicant to provide: (1) The appropriate fees, including the application fee which shall not be refunded; (2) The applicant’s full name; (3) The applicant’s birthplace, and birthdate; (4) A completed Federation Discipline Report from the Federation of State Medical Boards; (5) A completed discipline report from the National Practioners Data Bank; (6) A completed profile from the American Medical Association; (7) Evidence of passage of the requisite examinations; (8) If a graduate of a medical school accredited by the Liaison Committee on Medical Education, evidence of graduation from a medical school accredited by the Liaison Committee on Medical Education, and evidence of having served, for at least one year, in a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or in a program whose standards are equivalent to the ACGME standards as determined by the board; (9) If a foreign graduate, evidence that the applicant is a graduate of a foreign medical school, has served for at least two years in a residency program accredited by the ACGME, and holds the national certificate of the Educational Commission for Foreign 85-6 §16-85-7 Medical Graduates, (ECFMG) or the certificate of the Fifth Pathway Program of the American Medical Association; (10) Evaluation reports relating to the applicant’s conduct and competency from every hospital at which the applicant has applied for or held consultation or teaching appointments or privileges or has been employed in a residency program within the immediate three years preceding the application; (11) If applicable, evidence of any licenses held or once held in other jurisdictions indicating the status of the license and documenting any disciplinary proceedings pending or taken by any jurisdiction; (12) Information regarding any conviction of any crime which has not been annulled or expunged; and (13) Any other information the board may require to investigate the applicant’s qualifications for license. (b) An application for a limited and temporary license shall be made under oath on a form provided by the board, and in addition to the items in subsection (a), shall require the applicant to provide: (1) If applying for a license due to absence or shortage of physicians in a particular locality; (A) Evidence of valid and current licensure in another state or U.S. territory; and (B) A statement from an official of the respective county medical society or from some other person or entity which in the sole discretion of the board satisfies the board as to the absence or shortage of physicians in the particular locality; (2) If applying as an employee of an agency or department of the state or county government; (A) Evidence of valid and current licensure in another state or U.S. territory; and (B) A statement from an official of the state or county agency or department confirming employment; (3) If applying to practice only while under the direction of a physician or physicians holding a current and valid license in this State; (A) A statement that the applicant intends to take the licensing examination within the next eighteen months; and (B) A signed statement from the licensed physician, also referred to as sponsor or the alternate sponsor, as the case may be, that the sponsor and alternate sponsor will be responsible for supervising the applicant. 85-7 §16-85-7 (4) If applying to practice as a resident in training, a letter signed by an authority at the institution verifying starting and ending dates of employment as a resident or verifying acceptance for residency training; (5) If applying for license due to a public emergency; (A) A statement describing the nature of the emergency; and (B) Evidence of valid and current licensure in another state or U.S. territory; and (6) If applying for an educational teaching license; (A) A written summary of the applicant’s medical, educational, and professional background; (B) Evidence of licensure in another state, U.S. territory, or country, and verification from the licensing authority of the state, U.S. territory, or country in which the applicant is licensed that the license is current and in good standing; and (C) A letter signed by the chief of service of a clinical department of a hospital attesting that the chief of service is licensed in this State and is requesting to sponsor and monitor the applicant while the applicant is engaged in educational or teaching activities for the hospital. (c) It shall be each applicant’s responsibility to furnish any information and documentation requested by the board. In the event of any change of information provided, the applicant shall notify the board in writing within thirty days of any change. (d) Every application and all references shall be signed by the applicant or the person attesting to the education, experience, and reputation of the applicant. [Eff l/27/79; am and ren §16-85-7, 6/12/81; am and comp 7/27/87; comp 10/28/89; comp 8/25/90; am and comp 12/22/97] (Auth: HRS §453-5.1) (Imp: HRS §§453-3.2, 453-4)