Application For A License To Practice Podiatric Medicine (Page 3 of 24) in pdf

GENERAL INFORMATION

ADDRESS OF RECORD

The application asks for your preferred address of record. This is the address to which you would like us to send all

communications to you including your permit or license. Please do not use third party addresses, telephone numbers, or email

addresses as this creates difficulties when we are trying to reach you.

APPLICATION FOR LICENSURE BY CREDENTIALS

The Alaska State Medical Board may waive the written examination requirement and license an applicant by credentials if

you hold an active license issued after written examination in another state or territory or the United States or province of

Canada. Such examination must be equivalent to the National Boards or the PMLexis examination series and have passed

those examinations with at least the minimum passing score as defined by regulation.

APPLICATION STATUS UPDATES

Our licensing examiner will send you a written status update upon the initial screening of the application and monthly

thereafter.

CERTIFIED TRUE COPIES

To obtain a certified true copy, take the original document to a notary public so he/she may compare the original to the

photocopy of the document. The notary must write “I certify this to be a true copy of the original document.” on the

photocopy and attest to the fact by signing and notarizing the document.

COMPLETION OF THE APPLICATION FORMS

Help us do a good job processing your application: type or print legibly all application documents. Please read the

instructions and give careful thought before answering the questions in the application - remember - you are certifying that

the information is truthful and correct. Make sure all notary seals are properly affixed on the application and all

documentation has been properly certified as required. Provide all documents requested in the application; incomplete

applications will delay processing.

Each question in the application must be answered. Attach separate sheets of paper, labeled with your name and signed by

you, for any question for which you have provided a YES response.

Failure to answer all questions completely and accurately, or the omission or falsification of information may be cause

for denial of your application or disciplinary action if you are subsequently permitted by the board. WHEN IN DOUBT,

DISCLOSE ALL INFORMATION OR CALL OUR OFFICE FOR ASSISTANCE.

CONFIDENTIALITY

The contents of licensing files are generally considered public records. If you believe that the additional information you

are attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request for

confidentiality may or may not be granted.

CONTINUING MEDICAL EDUCATION REQUIREMENT

Alaska law requires an average of 25 hours of Category I AMA- or AOA-approved continuing education hours for each

year of the licensing period (two-year licensing cycle). At the time of renewal, the licensee must attest to compliance with

the CME requirements. After renewal is completed, the division will perform a computer-generated random audit of

licensees who will be required to provide proof of CME courses. Please see regulations 12 AAC 40.200, 210, and 220.

DEA CLEARANCE REPORT

You are required to request a clearance report from the Drug Enforcement Administration for your DEA registration. Use

the form provided in this packet and send your request to:

Drug Enforcement Administration

300 5

Avenue, Suite 1300

Seattle, WA 98104

DENIAL OF LICENSE

The denial of an application for licensure is a public action and may be reported or disclosed to any person, professional

licensing board, federal, state, or local government agency, or other entity making a relevant inquiry or as may be required by

law.

EXAMINATION SCORES

Regardless of your application, whether by credentials or examination, Alaska requires that you must pass each

component of your examinations with a minimum two-digit score of 75. If you are applying for licensure by examination

and fail any component more than once, you will be required to complete a supervised course of study acceptable to the

board before permission to retake the step will be given.

08-4109 (Rev. 10/15/14)

Application Information

Page 2 of 5

Application For A License To Practice Podiatric Medicine Page 3

Related Articles

Related forms

Related Categories