Management Branch Office of Licensing

Physician (DR) Application Checklist Information about the application process and how you will be contacted An Application Specialist will review your application based on the information you supply. If your application is incomplete, you will be contacted via the email address you provided. To monitor the status of your application, visit Online Services: apps.colorado.gov/dora/licensing/Default. Disclosure of addresses: Consistent with Colorado law, all addresses and phone numbers on record with the Division of Professions and Occupations (DPO) are public record and must be provided to the public when requested. It is your responsibility to keep your address and contact information current in our system. Your email address is not open to public record, but must be provided at the time you register an account. If your email address is not current, it is possible you will not receive important information from DPO. You can change your address, email address and other information online by using Online Services: apps.colorado.gov/dora/licensing/Default. Application expiration: Your application will be kept on file for one year from date of receipt in the Division of Professions and Occupations. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to resubmit a new application packet and fee after that time. If you submitted an application within the last year and were notified that you did not meet the requirements and you are submitting an update, you do not need to complete a new application or submit additional fees. License expiration grace period for new applicants: PLEASE BE ADVISED that if you are issued a license within 120 days of the upcoming renewal expiration date, you will be issued a license with the subsequent expiration date. For example, licenses issued between January 1, 2019 and April 30, 2019 will reflect an expiration date of April 30, 2021. Licenses issued prior to January 1, 2019 will reflect an expiration date of April 30, 2019 and must renew in the upcoming renewal period. th

All Physician licenses expire on April 30 of odd-numbered years and must be renewed to continue practicing. Requirements for all physician applicants: Pay Required Fee: You must pay the $412 application processing fee with a credit card (American Express, MasterCard, Visa or Discover) or electronic check to complete the application process. All fees are nonrefundable and are subject to change. Be at least 21 years of age: You must be at least 21 years old in order to apply for physician licensure in Colorado. Provide a copy of your birth certificate or U.S. passport: You must be able to upload a copy of your birth certificate or U.S. passport at the time you apply online.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

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Provide and verify your Practice History: You must provide your practice history as a physician in chronological order beginning with completion of graduate school and including all internships, residency/fellowship training programs and non-medical employment. You must arrange for original letters of references be sent for the last five years. Letters must be provided from the original source on letterhead with dates listed as month/year. Submit the Request for FSMB Disciplinary Action Report: You must complete and submit the Request for Disciplinary Action Report Form directly to the Federation of State Medical Boards (FSMB). Do not send the request form to the Office of Licensing as this will delay processing of your application. Once FSMB completes your request, they will provide the completed form directly to the Office of Licensing. For further information or to submit your request, contact FSMB at (817) 868-4000 or visit their website: http://www.fsmb.org/. Your application will not be fully processed until this is received. Complete an online Self-Query and submit the results to the Office of Licensing: You must complete an online self-query for the National Practitioner’s Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB). You must then submit your self-query report to the Office of Licensing at the address on the bottom of this page. For further information or to submit your online self-query, contact NPDB-HIPDB at (800) 767-6732 or visit their website: www.npdb.hrsa.gov/index. Your application will not be fully processed until this is received. Complete the Affidavit of Eligibility: You will be asked when you apply online to attest to and provide information that you are lawfully present in the United States or otherwise eligible to work here. You may be required to upload documentation of your lawful presence. Provide your social security number or an Affidavit: As of January 1, 2009, a Social Security Number is required for all licenses/certifications. Exceptions are made for foreign nationals not physically present in the United States and for non-immigrants in the United States on student visas who do not have a Social Security Number. These applicants must submit a signed Social Security Number Affidavit in lieu of a Social Security Number. The Social Security Number Affidavit is available on the Division of Professions and Occupations (DPO) website: www.colorado.gov/dora/DPO_Update_Contact. Provide name change documentation (if applicable): If you already have another type of licenses/certifications in Colorado and your name has since changed, you are presenting documentation for licensure with a previous name, or if any required documentation has a different name on it, you will be required to upload proof of your name change. List and verify other licenses (if applicable): You will be asked to list ALL license(s) you hold or have held to practice medicine or a related profession. It is preferred that you provide scanned copy verification from the other state or jurisdiction website at the time you apply online. Malpractice Insurance: You must provide proof of Colorado malpractice insurance or a letter of exemption (per Rule 220) before your application will be fully processed. If you do not have malpractice insurance, you must obtain coverage in order to apply. If you have malpractice insurance valid in Colorado, you must arrange for your insurance carrier or Colorado postgraduate training program to submit an original statement to the Office of Licensing at the address on the bottom of this page indicating the policy number, dates of coverage and amounts of coverage. If the company is located outside of Colorado, the statement must also indicate that the coverage is effective while you practice in Colorado. If you qualify for an exemption per Rule 220, you must provide proof to establish your eligibility for such exemption. Answer the screening questions: You will be asked a series of screening questions related to your criminal history or complaints filed against you in other jurisdictions (if applicable). This may require you to upload court documents or other material. Please review DPO’s information regarding the disclosure of criminal history contained within these instructions.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions

Complete Healthcare Professions Profile: You will be asked a series of questions concerning your practice during your online application for the Healthcare Professions Profiling Program (HPPP). This profile is required for healthcare professionals in Colorado. Your Healthcare Professions Profile is an ongoing responsibility; you must update your profile online within 30 days of changes and/or reportable events. As you complete your profile, please read the instructions carefully. For more information visit: www.colorado.gov/dora/HPPP or call 303-894-5942. Requirements for those applying by ORIGINAL method: Hold a MD or DO degree from an approved medical school: You must have graduated from an approved medical school with a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree. You must use the Certificate of Medical Education Form to verify your degree. The form must be completed by you and the school from which you graduated and sent directly to the Office of Licensing at the address on the bottom of this page. The form is not valid without a school seal and your application will not be fully processed until this is received. If you graduated from a medical school outside the U.S. or Canada, you must: Obtain certification though ECFMG: If you graduated from a medical school outside the U.S. or Canada, you must hold a certification through the Educational Commission for Foreign Medical Graduates (ECFMG) and must arrange for ECFMG to send a Status Report of your Certification directly to the Office of Licensing at the address on the bottom of this page. Complete and Upload International Graduate Questionnaire: You must complete and upload the International Medical Graduate Questionnaire at the time you apply. You may not complete and submit your application unless your completed form is provided. You may access the questionnaire on the Applications and Forms webpage: www.colorado.gov/dora/Physician_Applications_Docs. Have completed at least one year of ACGME/AOA/CCME postgraduate training: You must have completed at least one year of postgraduate training approved by the Accredited Council for Medical Education (ACGME), American Osteopathic Association (AOA) or the Coordinating Council of Medical Education of the Canadian Medical Association (CCME). You must use the Certificate of Completion of ACGME/AOA/CCME Postgraduate Training form to verify at least one year of postgraduate training. The form must be completed by you and the facility where you received postgraduate training. You may upload the completed form at the time you apply online; otherwise, you must arrange for the completed form to be sent to the Office of Licensing at the address on the bottom of this page. Further training beyond the year may be verified with a letter from the training program. The Certificate of Completion of ACGME/AOA/CCME Postgraduate Training form is available on the Applications and Forms webpage: www.colorado.gov/dora/Physician_Applications_Docs. If you graduated from a medical school outside the U.S. or Canada, you must: Have completed three years of ACGME/AOA/CCME postgraduate training: You must have completed at least three years of postgraduate training approved by the Accredited Council for Medical Education (ACGME), American Osteopathic Association (AOA) or the Coordinating Council of Medical Education of the Canadian Medical Association (CCME). You must use the Certificate of Completion of ACGME/AOA/CCME Postgraduate Training form to verify your training. The form must be completed by you and the facility where you received postgraduate training. You may upload the completed form at the time you apply online; otherwise, you must arrange for the completed form to be sent to the Office of Licensing at the address on the bottom of this page. Further training beyond the three years may be verified with a letter from the training program. The Certificate of Completion of ACGME/AOA/CCME Postgraduate Training form is available on the Applications and Forms webpage: www.colorado.gov/dora/Physician_Applications_Docs.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions

Have passed *ONE of the following U.S. examinations and arranged for your scores to be sent to the Office of Licensing at the address on the bottom of this page: •

National Boards and the United States Medical Licensing Examination (USMLE) administered by the National Board of Medical Examiners; OR • National Osteopathic Board Examination administered by the national Board of Osteopathic Examiners; OR • Licentiate of the Medical Council of Canada (LMCC) administered by the Medical Council of Canada; OR • FLEX examination administered by the Federation of State Medical Boards of the United States, Inc.; OR • A state-constructed examination – however, you must hold a valid, unencumbered physician license in the state the exam was taken, or another state where you were licensed by reciprocity based on the original exam. *For more detailed information about examination requirements, review the Summary of Requirements and/or the USMLE Information available on the Applications and Forms webpage: www.colorado.gov/dora/Physician_Applications_Docs.

Requirements for those applying by ENDORSEMENT: Hold a physician license in another state or jurisdiction: You must hold a current, valid license in another state or jurisdiction with substantially similar qualifications for licensure to qualify by endorsement. You will be asked to list ALL license(s) you hold or have held to practice medicine or a related profession. You must provide verification of ONE current license you hold in another state or jurisdiction. It is preferred that you provide scanned copy verification from the other state or jurisdiction website at the time you apply online. Otherwise, arrange for verification to be sent to the Office of Licensing – Medical Licensure at the address on the bottom of this page. The verification must indicate whether or not you have ever had disciplinary action taken against your license. A copy of the license will not suffice. Demonstrate competency to practice: You must have actively practiced medicine in another state or jurisdiction for at least five of the seven years immediately preceding submission of your application. Postgraduate training does NOT count as active practice. Otherwise, you will be prompted to explain another method in which you can demonstrate you competency to practice.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions

IMPORTANT NOTICE TO:

All Applicants

FROM:

Director of the Division of Professions and Occupations

SUBJECT:

Licensure and Criminal History

Thank you for your interest in becoming a licensed* professional within the Division of Professions and Occupations. Before you submit your application, please be aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states. The mission of the Division of Professions and Occupations is “public protection through effective licensure and enforcement.” One way the Division safeguards consumers is by issuing licenses to fully qualified, competent, and ethical applicants. During the licensing process – and depending on the specific application – the Division may ask whether you have ever been disciplined in any state, arrested, charged, convicted, or pled guilty to a crime. An arrest, subsequent criminal conviction, or disciplinary action is not an automatic disqualification from licensure. Rather, the appropriate board or program will look at the facts surrounding the criminal conduct and disciplinary action in addressing your license application. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be complete and accurate in disclosing information on your application. Be sure to list all relevant complaints, disciplinary actions, arrests, charges, or convictions in response to the appropriate licensure questions. Failure to fully and accurately disclose requested criminal history information, alone, could constitute grounds for denial of your application or revocation of your license. When requested, you must include information regarding prior conduct. This remains the case when the conduct is seemingly unrelated to the activities of a profession, and when the conduct involves deferred sentences or judgments. Remember, even following licensure, you are still required to notify your professional licensing board or program about subsequent convictions and disciplinary actions in other states. Please be aware that the Division conducts audits of its licensing database against several criminal and national disciplinary databases. This allows the Division to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial licensure. Keep in mind, your license will not necessarily be revoked, or your application denied, if you have been disciplined, arrested, charged or convicted. But, you will most likely be denied or revoked if you fail to disclose requested information. *The word "license" is used as a general term. While most of the professions and occupations are licensed, others may be registered, certified, or listed. For precise terminology and requirements related to a profession or occupation, please consult the website of the appropriate board or program.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions