HEALTHLAWYER:

Sun	Mon	Tue	Wed	Thu	Fri	Sat
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30

To: My GMU HAP 750 Health Law Students

===============================

Please see the material quoted below and also the material contained
in the linked file, in connection with your written assignment for the
next class and for discussion during our next class. Thank you.

Quoted from Commonwealth of Virginia Legal References:

§§ 54.1-2900. Definitions.

"Practice of medicine or osteopathic medicine" means the prevention,
diagnosis and treatment of human physical or mental ailments,
conditions, diseases, pain or infirmities by any means or method.

§ 54.1-2903. What constitutes practice.
Any person shall be regarded as practicing the healing arts who
actually engages in such practice as defined in this chapter, or who
opens an office for such purpose, or who advertises or announces to
the public in any manner a readiness to practice or who uses in
connection with his name the words or letters "Doctor," "Dr.," "M.D.,"
"D.O.," "D.P.M.," "D.C.," "Healer," or any other title, word, letter
or designation intending to designate or imply that he is a
practitioner of the healing arts or that he is able to heal, cure or
relieve those suffering from any injury, deformity or disease. No
person regulated under this chapter shall use the title "Doctor" or
the abbreviation "Dr." in writing or in advertising in connection with
his practice unless he simultaneously uses a clarifying title,
initials, abbreviation or designation or language that identifies the
type of practice for which he is licensed.
Signing a birth or death certificate, or signing any statement
certifying that the person so signing has rendered professional
service to the sick or injured, or signing or issuing a prescription
for drugs or other remedial agents, shall be prima facie evidence that
the person signing or issuing such writing is practicing the healing
arts within the meaning of this chapter except where persons other
than physicians are required to sign birth certificates.

Rev. 03/10

INSTRUCTIONS FOR COMPLETING AN APPLICATION TO PRACTICE MEDICINE IN VIRGINIA
FOR GRADUATES OF AMERICAN MEDICAL SCHOOLS ( US/CANADA)
(This form has been designed for you to use as a checklist for
processing your application)

The applicant is responsible for forwarding all of the required forms
to the appropriate institutions, states and other agencies.

Application and Fee – The four (4) page application along with the
required fee of $302.00 must be submitted together. Please make all
checks and/or money orders made payable to the Treasurer of Virginia.
Applications received without fees and fees received without
applications will be returned the same day of receipt. The
application and fee may not be faxed.

Examination Scores –

If you took the FLEX examination or all three steps of the USMLE
examination, contact the Federation of State Medical Boards at
(817)868-4000 or www.fsmb.org for fee information and to have your
scores submitted to the Board. Scores may not be faxed and must come
directly from the Federation. If using the FCVS Credentialing
Service, your scores will be included.

If you took the National Board examination or a combination of the
USMLE examination, please contact the National Board of Medical
Examiners at (215)590-9500 or www.nbme.org for fee information and to
have your scores submitted to the Board. Scores may not be faxed and
must come directly from the National Board.

If you took the LMCC examination, please contact that agency to have
your scores submitted to the Board. This document may not be faxed.

If you took a state examination, please contact that examining board
to have your scores submitted to the board. Please note: If you took
a state examination after 1969, you must be American board certified
in a specialty to be eligible for licensure. If applicable, please
submit a copy of your specialty certificate. Scores may not be faxed,
however the specialty certificate may be.

Proof of Professional Education (Form L) – This form must be
completed by your professional school. This form may be faxed to your
medical school, but the completed form may not be faxed to the Board.
If using the FCVS Credentialing Service, proof of your education will
be included.

Transcripts – Transcripts must be official, with the school seal.
Transcripts will be accepted if they come directly from the school to
the Board or if sent to the Board by the applicant in a sealed
envelope. This document may not be faxed. If using the FCVS
Credentialing Service, medical school transcripts will be included.

Claims History Sheet (Form A) - Claims History Sheet - If you have
had malpractice cases brought against you (pending or closed), please
complete form A with details of each case. If this does not apply to
you, please disregard. This form may be faxed.

Employment Activity Questionnaire (Form B) – List activities on the
chronological page of the application, (Page 4) to include all
activities since graduation from your professional school. Forward
Form B (Activity Questionnaire) to those places of practice/employment
listed for the past five (5) years or since graduation, whichever
applies. If engaged in private practice, without hospital
affiliations, have another physician submit a letter attesting to your
practice. CV’S ARE NOT ACCEPTABLE. IF SUBMITTED IN LIEU OF PAGE 4,
YOUR APPLICATION MAY BE RETURNED FOR COMPLETION. This form may be
faxed. (Page 4 may be copied for additional activities and attached
to application.)

Jurisdiction Clearance (Form C) – Forward this form to those
jurisdictions in which you have been issued a full license,
certification or registration. This form may be copied as necessary.
Please contact the applicable jurisdictions to inquire about
processing fees. This form may be faxed directly from the
jurisdiction

AMA Physician Profile – Visit the AMA website at
http://www.ama-assn.org/amaprofiles/ to order a profile. This document
may be faxed.

Disciplinary Inquiry (Form E) – Contact the Federation of State
Medical Boards at (817)868-4083 to request a Disciplinary Inquiry or
go to www.fsmb.org to complete the online form. This documentation may
be faxed. If you are using the FCVS Credentialing Service and have
taken the FLEX or USMLE, the disciplinary inquiry will be provided.
Also, if you have taken the FLEX or USMLE, the score report will
include a disciplinary inquiry.

Postgraduate training - If your required postgraduate training was
completed over five years ago, and will not be verified on a form B,
please supply a copy/copies of certificates. This documentation may
be faxed.

Military Service – If you have been discharged from the United States
Military Service within the past ten (10) years, submit a copy of
your discharge papers. This document may be faxed.

Please note:

*Your application shouldl be reviewed within a week or two of receipt.
You will be notified by mail or email. Please allow at least 3 weeks
for processing before contacting the Board office for a status report.

*Please be aware that consistent with Virginia law and the mission of
the Department of Health Professions, addresses on file with the Board
of Medicine are made available to the public. This has been the
policy and the practice of the Commonwealth for many years. However,
with the application of new technology, which makes this information
more accessible, there has been growing concern of those licensees who
supply their residence address for mailing purposes. This notice is
to reiterate that the Board of Medicine maintains only one address for
each licensee and will allow the address of record to be a Post Office
Box or practice location.

*Applications not completed within 6 months may be purged without
notice from the board. Application fees will remain valid for up to
one year after receipt.

*Applications are not submitted for review until all supporting
documents appear to be received. Additional information may be
requested upon review.

*Application Fees are non-refundable.

*A formal letter will be sent to you after approval of licensure. Do
not begin practice until you have been notified of approval.
Submission of an application does not guarantee a license. A review
of your application could result in the finding that you may not be
eligible pursuant to Virginia laws and regulations.

*Certain forms may be faxed to 804-527-4426.

*Contact the Licensing Specialist at 804-367-4471

Rev. 11/07 MEDICINE & SURGERY

Application for a License to
Practice Medicine & Surgery

I hereby make application for a license to practice
Medicine and Surgery in the Commonwealth of
Virginia and submit the following statements:

Last

First
Street Address

City/State
Date of Birth

_______/_______/_______

Place of Birth Social Security/VA Control #
Professional School Name & Location

Professional School Graduation Date

_______/_______/_______

Please accompany with this application a check or money order made
payable to the Treasurer of Virginia in the required amount. If the
money does not accompany the application, the application will be
returned. Please submit address changes in writing immediately.

*In accordance with §54.1-1116 in the Code of Virginia, you are
required to submit your Social Security number/Control number (issued
by the Virginia Department of Motor Vehicles.). This number will be
used by the Department of Health Professions for identification
purposes only and will not be disclosed for any other purposes except
as mandated by law. Federal and State law requires that this number be
shared with other state agencies for child support enforcement
activities. Failure to disclose this number will result in the denial
of a license to practice in the Commonwealth of Virginia.

APPLICANTS DO NOT USE SPACES BELOW THIS LINE – FOR OFFICE USE ONLY

APPROVED BY: ______________________________________________________________________________
Applicant # Check # Class #

0101 Fee

$302.00

1. List in chronological order all professional practices since
graduation, including internships, residencies, hospital affiliations
and absences from work. Also list all periods of non-professional
activity or employment for more than three months. PLEASE ACCOUNT FOR
ALL TIME. If engaged in private practice, list all hospital
affiliations. If none, please explain. A completed Form B must be
received for all places listed for the last five years.

From To Name &
Location Position Held

____________ ___________
______________________________________________________
__________________________________

______________________________________________________

______________________________________________________

____________ ___________ ___________...

2. Please provide a telephone number where you can be reached during
the day. This information is not mandatory and if provided will not
be used for any purpose other than as a contact if the licensing
specialist has questions about your application.
Home #: Work #:
Email Address:

These questions must be answered in order for your application to be
considered complete. If any of the following questions (#6-15) is
answered yes, please provide supporting documentation. Letters must
be submitted by your attorney regarding malpractice suits (or you may
complete and submit Form A yourself.)

3. I hereby certify that I studied medicine and received the degree of
_______________________________________ on __________________

(degree) (date)

from _____________________________________________________________________.
Name of School

4. Do you intend to engage in the active practice of medicine in the
Commonwealth of Virginia? Yes No

5. List all jurisdictions in which you have been issued a license to
practice medicine/osteopathy. Include the number and date issued of
all active, inactive or expired licenses.
Jurisdiction Number Issued Active/Inactive/Expired

6.Which of the following have you taken: National Boards
Examination; USMLE Step 1; USMLE Step 2; USMLE Step 3; Flex

Please list the locality and the number of attempts taken for all
those selected above.__________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Have you ever been denied a license or the privilege of taking a
licensure/competency examination by any licensing authority? Yes
No

If yes, please explain:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Have you ever been convicted of a violation of/or pled Nolo
Contendere to any federal, state or local statute,
Yes No
regulation or ordinance, or entered into any plea bargaining
relating to a felony or misdemeanor? (Excluding
traffic violations, except convictions for driving under the influence.)

9. Have you ever been denied privileges or voluntarily surrendered
your clinical privileges while under investigation,
Yes No
been censured or warned, or requested to withdraw from the staff of
any medical school, residency or fellowship
training, hospital, nursing home, or other health care facility, or
health care provider?

10.Have you ever had any of the following disciplinary actions taken
against your license to practice medicine,
Yes No
DEA permit, state controlled substances registration, Medicaid, or
any such actions pending?
(a) suspension/revocation (b) probation (c) reprimand/cease and
desist (d) had your practice monitored
(e) limitation placed on scheduled drugs?

11. Have you ever had any membership in a state or local professional
society revoked, suspended, or sanctioned? Yes
No

12. Have you voluntarily withdrawn from any professional society
while under investigation? Yes No

13. Have you had any malpractice suits brought against you in the
last ten (10) years? If so, how many? _____
Yes No

14. Have you been physically or emotionally dependent upon the use of
alcohol/drugs or treated by, consulted with, Yes
No
or been under the care of a professional for any substance
abuse within the last two years? If so, please provide
a letter from the treating professional.

15. Do you have a physical disease, mental disorder, or any
condition, which could affect your performance of professional
Yes No
duties? If so, provide a letter from your treating professional
to include diagnosis, treatment, prognosis and fitness to
practice.

(THIS SECTION MUST BE NOTARIZED)

I, ______________________________________________________, being
first duly sworn, depose and say that I am the person referred to in
the foregoing
application and supporting documents.
I hereby authorize all hospitals, institutions, or organizations, my
references, personal physicians, employers (past and present),
business and professional
associates (past and present), and all governmental agencies and
instrumentalities(local, state, federal, or foreign) to release to the
Virginia Board of Medicine any
information, files or records requested by the Board in connection
with the processing of individuals and groups listed above, any
information , which is material
to me and my application.
I have carefully read the questions in the foregoing application and
have answered them completely, without reservations of any kind, and I
declare under
penalty of perjury that my answers and all statements made by me
herein are true and correct. Should I furnish any false information in
this application, I hereby
agree that such act shall constitute cause for the denial,
suspension, or revocation of my license to practice medicine and
surgery in the Commonwealth of
Virginia.
I have carefully read the laws and regulations related to the
practice of my profession which are available on www.dhp.virginia.gov
, and I fully understand that
Funds submitted as part of the application process shall not be refunded.

__________________________________________________________
Signature of Applicant

City/County of _________________________________________________
State of _______________________________________________

Subscribed and sworn to before me this ________________________ day
of ______________________________________ 20_____________.

My Commission expires _______________________________.

_________________________________________________
Signature of Notary Public
NOTARY SEAL

===============

As used in this chapter, unless the context requires a different meaning:
"Board" means the Board of Nursing.
"Certified nurse aide" means a person who meets the qualifications
specified in this article and who is currently certified by the Board.
"Clinical nurse specialist" means a person who is registered by the
Board in addition to holding a license under the provisions of this
chapter to practice professional nursing as defined in this section.
Such a person shall be recognized as being able to provide advanced
services according to the specialized training received from a program
approved by the Board, but shall not be entitled to perform any act
that is not within the scope of practice of professional nursing.
"Certified massage therapist" means a person who meets the
qualifications specified in this chapter and who is currently
certified by the Board.
"Massage therapy" means the treatment of soft tissues for therapeutic
purposes by the application of massage and bodywork techniques based
on the manipulation or application of pressure to the muscular
structure or soft tissues of the human body. The terms "massage
therapy" and "therapeutic massage" do not include the diagnosis or
treatment of illness or disease or any service or procedure for which
a license to practice medicine, nursing, chiropractic therapy,
physical therapy, occupational therapy, acupuncture, or podiatry is
required by law.
"Practical nurse" or "licensed practical nurse" means a person who is
licensed or holds a multistate licensure privilege under the
provisions of this chapter to practice practical nursing as defined in
this section. Such a licensee shall be empowered to provide nursing
services without compensation. The abbreviation "L.P.N." shall stand
for such terms.
"Practical nursing" or "licensed practical nursing" means the
performance for compensation of selected nursing acts in the care of
individuals or groups who are ill, injured, or experiencing changes in
normal health processes; in the maintenance of health; in the
prevention of illness or disease; or, subject to such regulations as
the Board may promulgate, in the teaching of those who are or will be
nurse aides. Practical nursing or licensed practical nursing requires
knowledge, judgment and skill in nursing procedures gained through
prescribed education. Practical nursing or licensed practical nursing
is performed under the direction or supervision of a licensed medical
practitioner, a professional nurse, registered nurse or registered
professional nurse or other licensed health professional authorized by
regulations of the Board.
"Practice of a nurse aide" or "nurse aide practice" means the
performance of services requiring the education, training, and skills
specified in this chapter for certification as a nurse aide. Such
services are performed under the supervision of a dentist, physician,
podiatrist, professional nurse, licensed practical nurse, or other
licensed health care professional acting within the scope of the
requirements of his profession.
"Professional nurse," "registered nurse" or "registered professional
nurse" means a person who is licensed or holds a multistate licensure
privilege under the provisions of this chapter to practice
professional nursing as defined in this section. Such a licensee shall
be empowered to provide professional services without compensation, to
promote health and to teach health to individuals and groups. The
abbreviation "R.N." shall stand for such terms.
"Professional nursing," "registered nursing" or "registered
professional nursing" means the performance for compensation of any
nursing acts in the observation, care and counsel of individuals or
groups who are ill, injured or experiencing changes in normal health
processes or the maintenance of health; in the prevention of illness
or disease; in the supervision and teaching of those who are or will
be involved in nursing care; in the delegation of selected nursing
tasks and procedures to appropriately trained unlicensed persons as
determined by the Board; or in the administration of medications and
treatments as prescribed by any person authorized by law to prescribe
such medications and treatment. Professional nursing, registered
nursing and registered professional nursing require specialized
education, judgment, and skill based upon knowledge and application of
principles from the biological, physical, social, behavioral and
nursing sciences.

===============

MEDICARE ENROLLMENT APPLICATION

PHYSICIANS AND
NON-PHYSICIAN PRACTITIONERS
CMS-855I

DOWNLOAD PLEASE:

https://www.cms.gov/cmsforms/downloads/cms855i.pdf

HEALTHLAWYER

Welcome to HEALTHLAWYER, Alan S. Goldberg's HEALTHLAWYERBLOG(sm) providing health law education and information for lawyers and law and other students. PLEASE SEE DISCLAIMER BELOW © Copyright 2011, Alan S. Goldberg. All rights reserved.

About

Recent Posts

November 2011

Archives

May 27, 2011

Legal Iss Relevnt Hlthcare Adm - GMU HAP 750 - Summer 2011

May 26, 2011

Legal Iss Relevnt Hlthcare Adm - GMU HAP 750 - Summer 2011