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“... ation will require you to download a supplemental form and submit it. Some of the forms must be sent to a third party, such as your medical school or liability carrier. Applicants must also take and pass the Jurisprudence Exam and submit their fingerprints for state and national criminal ... ”
“... nline click here
Name Change Request Form
Verification Request Form
Printable Tanning Advisory
Complaint Notice Poster - Private Autopsy Facility
Consent Form for Abortion Procedure on a Minor
Health Care Liability Claims Report - Update ... ”
“... ation checklist, or licensure staff. Although the form may be designed for your license type, it may not be required.
Adobe Acrobat Reader is needed to view PDF files.
Additional Licensure forms are available under Forms. ”
“... ation will require you to download a supplemental form and submit it. Some of the forms must be sent to a third party, such as your physician assistant school or liability carrier. Applicants must also take and pass the Jurisprudence Exam and submit their fingerprints for state and natio ... ”
“...
Chief Medical Officer Designation/Contact Form
Compromise of Medical Judgement Report Form
The bill requires that a hospital directly hiring physicians appoint a chief medical officer and put in place policies to ensure that a physician employed by the hospital exercises the physicia ... ”
“This Form has been adopted by the Texas Medical Board in accordance with the requirements of §164.052(c), Texas Occupations Code (enacted by SB 419, 79th Legislature, 2005) and is published in 22 Texas Administrative Code §165.6(f). The purpose of this Form is to allow the physician to obt ... ”
“... th certificate or passport.
Dean's Certification (Form D). This form can be found by clicking the Supplemental Forms link to the left and selecting Licensing Forms PA. Request that each PA school you attended submit both of these forms to you in a sealed envelope with a signature of a PA school offi ... ”
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To activate your license for the first time, you need to pay your first time registration fee within 90 days of your license issue date. To maintain an active license, you will need to renew your registration biennially.
For any questions related to the renewal, please contact us at Reg ... ”
“... licensees who choose to register through a paper form, when an online option is available. If an online option is not available (ex: license is delinquent or suspended at the time of registration) the additional processing fee will not be required.
To request a hard copy registration f ... ”
“... nse, complete and return the cancellation request form (link below) to the Board for approval before the expiration date of the current registration permit. Refunds of registration fees already paid cannot be made.
Notification will be sent if the physician does not qualify for cancellation du ... ”
“... ation will require you to download a supplemental form and submit it, along with any third party documentation requested. Your application will not be considered complete until all supplemental information is received and processed. Your permit will be issued only when all requested information has ... ”
“... ed for cause, revoked or subject to another form of discipline in a state or territory of the United States, Canada, or a uniformed service of United States.
an investigation or proceeding pending for the restriction, cancellation, suspens ... ”
“... ation will require you to download a supplemental form and submit it. Some of the forms must be sent to a third party, such as your medical school or liability carrier. Applicants must also take and pass the Jurisprudence Exam and submit their fingerprints for state and national criminal ... ”
“... riod is defined as 72 hours. Please use the form below for notification of unanticipated transfer/hospitalization or death.
Unanticipated Transfer/Hospitalization or Death
Please contact the Registration Department at Registrations@tmb.state.tx.us if you have any additional quest ... ”
“Online Supervision and Prescriptive Delegation Registration System - Click to access system.
Use the online system to register prescriptive authority AND to file the notice of intent to practice/supervise as required of PAs and physicians. Hard copy supervision and delegation forms are no lon ... ”
Description: Press Release September 06, 2000 (PDF File)
Document: ... ysician, and must submit a completed registration form as a part of annual renewal. For copies of rule changes or proposed rules, write the Board at MC 901, P.O. Box 2018, Austin, TX 78768-2018, or e-mail jill.wiggins@t mb.state.tx.us
Description: Press Release September 06, 2005 (PDF File)
Document: ... an Temporary Licenses, where there is a link to a form listing all the requirements for the new permits, which may be faxed to (512) 305-7009. TMB is dedicated to its mission to protect the public by assuring that only qualified physicians treat patients in Texas, while making the process of admitti ...
Description: Press Release September 08, 2011 (PDF File)
Document: ... f another physician on a counterfeit prescription form and using those prescriptions to obtain medications. Orlov, Alexander, D.O., Lic. No. J4402, Lufkin On August 26, 2011, the Board and Alexander Orlov, D.O., entered into an Agreed Order of Voluntary Revocation requiring Dr. Orlov to immediately ...
Description: Press Release September 10, 2008 A (PDF File)
Document: Texas Medical Board News Release FOR IMMEDIATE RELEASE Wednesday, September 10, 2008*
Media contact: Public Information Officer Jill Wiggins at jill.wiggins@tmb.state.tx.us or (512) 305-7018. Non-media contact: (512) 305-7030 or (800) 248-4062.
Medical Board Disciplines 70 Doctors and Issues 700 P ...
Description: Press Release November 13, 2009 (PDF File)
Document: ... es, and repeal of §175.4, relating to Application Form. Chapter 179, Investigations: amendments to §179.4, relating to Request for Information and Records from Physicians. Chapter 180, Texas Physician Health Program and Rehabilitation Orders: amendments to new rule §180.1, relating to Rehabilitation ...
Description: Press Release February 23, 2012 (PDF File)
Document: ... Stogre. Because Dr. Stogre did not respond in any form to the Formal Complaint, the allegations are deemed true. VOLUNTARY SURRENDER Connolly, Jule Tom, M.D., Lic. No. C6899, Austin On February 10, 2012, the Board and Jule Tom Connolly, M.D., entered into an Agreed Order of Voluntary Surrender in wh ...
Description: Press Release April 25, 2012 (PDF File)
Document: ... utically prescribed and post-dated a prescription form for a controlled substance Mardock, Julian King, M.D., Lic. No. E6492, McKinney On April 13, 2012, the Board and Julian King Mardock, M.D., entered into an Agreed Order publicly reprimanding Dr. Mardock and prohibiting Dr. Mardock from practicin ...
Description: Press Release December 06, 2007 A
Document: ... ion in recordkeeping, revise his informed consent form for intravenous infusions, and pay an administrative penalty of $5,000. The action was based on his inadequate medical records for a patient and his use of an insufficient informed consent form. KONJOYAN, THOMAS R., D.O., Nederland, TX, Lic. #G2 ...
Description: Press Release December 18, 2012 (PDF File)
Document: Texas Medical Board Press Release
FOR IMMEDIATE RELEASE December 18, 2012
Media contact: Leigh Hopper, 512-305-7018 Customer service: 512-305-7030 or 800-248-4062
Texas Medical Board suspends or restricts 21 licensees in pain clinic crackdown
Seventeen physicians and four physician assistants invol ...
Description: Press Release December 14, 2001 (PDF File)
Document: ... anslation of the complaint procedure notification form. Proposed Rules The Board proposed the following rule changes for publication in the Texas Register and comment: Chapter 161, General Provisions: rule review and repeal and replace chapter. The proposal will outline the purpose and function
of ...
Description: TEXAS PHYSICIAN ASSISTANT BOARD BOARD MEETING December 3, 2010
Document: ... . Board staff presented an updated travel voucher form with checklist for board members to use for a more efficient reimbursement process. Legislative Update. Ms. Robinson gave an update on proposed legislation and the possible negative impact of future budget cuts in the upcoming legislative sessio ...
Description: TEXAS STATE BOARD OF PHYSICIAN ASSISTANT EXAMINERS LICENSURE COMMITTEE MEETING MINUTES FEBRUARY 28, 2003
Document: ... controlled substances, or dangerous drugs in any form unless prescribed by a physician; (2) submit him/herself for appropriate examinations, including screening for alcohol or drugs, at the request of a representative of the Board; (3) be solely responsible for the payment of all costs and charges ...
Description: PA Board 2011 February, Full Board
Document: ... he Board directed staff to revise the application form for future applicants to confirm that the physician assistant program is accredited at the time of graduation. There were no items for Agenda Item #.6 Agenda item #7, Consideration and Approval of Agreed Board Orders. After discussion, Mr. Rahr ...
Description: PA Board 2009 July, Full Board
Document: TEXAS PHYSICIAN ASSISTANT BOARD BOARD MEETING July 17, 2009 The meeting was called to order at 11:36 a.m. by Presiding Officer, Margaret K. Bentley. Board members present were Anna Chapman; Teralea Jones, PA-C; Felix Koo, M.D.; Michael A. Mitchell, D.O.; Richard R. Rahr, Ed.D, PA-C; Abelino Abel Rey ...
Description: PA Board 2004 July, Licensure
Document: TEXAS STATE BOARD OF PHYSICIAN ASSISTANT EXAMINERS LICENSURE COMMITTEE MEETING MINUTES JULY 30, 2004
The meeting was called to order at 10:06 a.m. by Chairman, Tony Hedges, D.O. Committee members present were Michael Belgard, PA-C; G. Al Bendeck, PA-C; and Pamela W. Clark. Jerry Walker, Deputy Exec ...
“... this time, only physician applicants can use the Form Y to expedite an application. Should this change, notification will be posted. ”
Can I expedite my physician assistant application?
At this time, only physician applicants can use the Form Y to expedite an application. Should this change, notification will be posted.
“... cant. Applicants can find the appropriate request form on our website at Supplemental Forms "Form N". ”
My licensing analyst informed me that I need a foreign education evaluation. What do I need to do?
A foreign education evaluation is one tool the board uses in evaluating the medical education of a physician applicant who attended a medical school located outside the United States. The board will accept evaluations from the Foreign Credentials Service of America (FCSA). The cost of the evaluation is borne by the applicant. Applicants can find the appropriate request form on our website at Supplemental Forms "Form N".
“... ird party identification number or choose another form of payment. ”
Can my residency program (or other third party) pay my PIT application fee?
Yes. They must register with the TMB for bulk payment processing. Your program will receive a third party identification number which they should make available to you, if they wish to pay your application fee. On the payment page of the online application, select "Pay by Third Party Payment". Enter the third party identification number you were given in the "Third Party ID" field. Note: This number should not be confused with the TMB personal identification number, or your ACGME, AOA, or TMB Program Identification number. Be sure to enter a valid email address. You will receive an email if the application fee has not been paid within seven days. Your application will not be submitted to the Texas Medical Board until the fee has been paid. Entering an incorrect third party identification number will mean that your program, or other third party payer, is prevented from paying for your application, and you will have to submit a new application with the correct third party identification number or choose another form of payment.
“... your request, a completed Name Change Application form and a notarized copy of the legal document(s) that granted your name change, i.e. marriage license, divorce decree etc. ”
What do I need to do to change the name I use professionally?
You must provide us with a statement that gives an explanation of your request, a completed Name Change Application form and a notarized copy of the legal document(s) that granted your name change, i.e. marriage license, divorce decree etc.
“... cannot use the online system, a Change of Address form is available, but not required. Information on the new Change of Address system is available at: http://www.tmb.state.tx.us/page/change-address ”
Can I give my change of address over the phone?
No. However, changes in mailing or practice addresses can now be updated online in most situations. For those license types that cannot use the online system, a Change of Address form is available, but not required. Information on the new Change of Address system is available at: http://www.tmb.state.tx.us/page/change-address
“... at least 5 working days for the processing of the form, the fee and posting to the computer system. ”
Is the registration payment due before the expiration of a license?
Yes. The completed registration application and payment are due on or before the expiration date of the permit. However, you should allow at least 5 working days for the processing of the form, the fee and posting to the computer system.
“... ensees who choose to register through a hard copy form, when an online option is available. If an online option is not available (ex: license is delinquent or suspended at the time of registration) the additional processing fee will not be required. ”
Is it the same price to register online or by hard copy?
No. An additional processing fee of $50 will be charged to those licensees who choose to register through a hard copy form, when an online option is available. If an online option is not available (ex: license is delinquent or suspended at the time of registration) the additional processing fee will not be required.
“... istration, please submit a hard copy registration form with the correct pro-rated fee. Please note that payments for the incorrect OBA pro-rated fee will be voided, causing a delay in the registration process. You may email us to request a pro-rated registration form at registrations@tmb ... ”
How much does OBA registration cost?
The biennial registration fee for office-based anesthesia is a total of $210, per physician and should be combined with the biennial registration.
For off cycle OBA registration, please submit a hard copy registration form with the correct pro-rated fee. Please note that payments for the incorrect OBA pro-rated fee will be voided, causing a delay in the registration process. You may email us to request a pro-rated registration form at registrations@tmb.state.tx.us.
“... lity. A physician must report on the registration form if she or he has completed the required CME. However, newly licensed physicians are exempt from the CME requirements the first time they register. ”
Is a physician required to complete CME to register a license?
Yes. Physicians need to complete at least 24 hours of continuing medical education each year, at least half of which must be in formal courses. One hour of formal CME must be in medical ethics and/or professional responsibility. A physician must report on the registration form if she or he has completed the required CME. However, newly licensed physicians are exempt from the CME requirements the first time they register.
“... fax). Please use the PMC change of address form located here. ”
How do I submit a name change or change of address for my pain management clinic?
A name change or change of address for a registered pain management clinic must be submitted in writing (by mail or fax). Please use the PMC change of address form located here.
“... d directly to the state board of your request.The form is avaliable under Verification Request in the "Licensee Resources" section of our website. ”
How do I get a verification of my Texas license sent to another state?
Upon written request TMB will provide a state board verification to another state board regarding licensees. The verification includes: licensee's name, license or permit number, issue date, expiration date, disciplinary status, and our board seal will be affixed.
There is no fee for state board verifications. Please allow 10 working days to process your verification. The verification will be mailed directly to the state board of your request.
The form is avaliable under Verification Request in the "Licensee Resources" section of our website.
“... to set up an e-prescribing process. On the waiver form, you will have to specify any of the above categories you are experiencing. ”
How do I qualify for the waiver?
There are three different ways you can qualify for a waiver. If you or your practice is experiencing any of the following, you may qualify for a waiver:
On the waiver form, you will have to specify any of the above categories you are experiencing.