Affidavit explaining medical residency for i application

Oath or Affirmation
All yes answers must be accompanied by a sworn affidavit. A sworn affidavit is an explanation (in applicant’s own words) that must be typed and notarized. Note: If the Oath or Affirmation is incomplete or inaccurate, or if criminal history is found that you did not disclose, you will be required to submit a new Oath or Affirmation, a notarized affidavit as to why you did not disclose the information and a new processing fee equal to the initial licensure fee. It is important that you answer all questions fully, accurately and truthfully. Any discrepancy, inaccuracy or incomplete information on the Oath or Affirmation may be viewed by the Board as attempting to obtain a license by means of fraud, and may be a reason for the license application to be denied. Do not take the advice of friends, lawyer, etc.

Third Party Authorization
This form must be notarized. It authorizes LSBME to obtain information concerning the applicant from third parties.

Statement of Legal Name
Record your name as it appears on each document listed that applies to you. This form must also be completed by any person whose name is not the same as the name on the birth certificate. This form must be notarized.

FCVS
You must complete the FCVS application in order to apply for licensure.

Background Check - NOTE: If you are a physician on a current LSBME training permit, you do not need to do another background check when applying for full licensure. LSBME conducts background checks as part of the application process. Instructions and forms can be found at the link above.

Qualifications for Licensure - International Medical Graduates

• Be at least 21 years of age and of good moral character;
• Be a citizen of the United States or possess valid and current legal authority to reside and work in the United States duly issued by the commissioner of the Immigration and Naturalization Service;
• Possess a Doctor of Medicine degree duly issued by a medical school approved by the board. This diploma must be in English; if not, must be accompanied by a certified translation into English;
• Applicant must have completed three years of ACGME approved residency training in the United States or Canada in the same specialty;
• Have taken and passed FLEX/USMLE Steps 1, 2, and 3 or a combination thereof.(There is no limit on step 1, four on Step 2 and four on step 3).
• Have taken and passed the ECFMG examination and have a valid certificate;
• If a medical competency examination has not been taken within 10 years of application, the applicant must be board certified or re-certified through the American Board of Medical Specialties within the past ten years or the applicant must take and pass SPEX (Special Purpose Examination) administered through the Federation of State Medical Boards, Inc.

Qualifications for Licensure - U.S./Canadian Graduates

• Be at least 21 years of age and of good moral character;
• Be a citizen of the United States or possess valid and current legal authority to reside and work in the United States duly issued by the commissioner of the Immigration and Naturalization Service;
• Possess a Doctor of Medicine degree duly issued by a medical school approved by the Board. The diploma must be in English.If not, must be accompanied by a certified translation into English;
• Have taken and passed either the state board examination, National Boards Parts 1, 2, and 3, FLEX, USMLE, COMLEX-USA, NBOME or a combination thereof. (There is no limit on step 1, four on Step 2 and four on step 3).
• If a medical competency examination has not been taken within 10 years of application, the applicant must be board certified or re-certified through the American Board of Medical Specialties or the American Osteopathic Association within the past ten years or the applicant must take and pass SPEX (Special Purpose Examination) administered through the Federation of State Medical Boards, Inc or COMVEX-USA administered by the National Board of Osteopathic Examiners.
• With respect to applications for licensure received by the board on and after January 1, 2019, a graduate of an American or Canadian medical school must have completed at least two years, or alternatively have completed one year and have a current commitment in a form and manner specified by the board for a second year, of postgraduate clinical training in the United States or in Canada in a medical residency or equivalent program accredited by the ACGME, AOA, or by the RCPS and approved by the board. For physicians pursing training in oral and maxillofacial surgery, one year of such training may be in a program accredited by the Commission on Dental Accreditation of the American Dental Association.

Additional Requirements

Fees
Fee must be paid via credit/debit card (Visa, MasterCard or Discover only)
​Fee is non-refundable.

• Licensure- $382.00 (MD/DO).

Birth Certificate/Valid Visa

• U.S. citizen - submit a notarized or certified copy of your birth certificate.
• U.S. citizen not born in the U.S. - submit a notarized copy of your certificate of citizenship, consular report of birth abroad or certificate of naturalization.
• Non-U.S. citizen - submit a notarized copy of current proof of citizenship. Acceptable forms of citizenship are an H1B Visa, J1 Visa, O1 Visa, TN Visa, Permanent Resident card or Employment Authorization card.
• Louisiana law (LA RS: 37.12) requires a valid permit to live and work in the United States to practice medicine.
• J1 Visas are structured for training and educational purposes only. The typical sponsor for a Medical Doctor’s J1 Visa is the ECFMG. A J1 visa is not for employment outside of a formal training program.
• H1B Visas are intended for those who are performing a specialized service or occupation. These Visas are usually sponsored by hospitals or a particular employer.
• The LSBME works with the United States INS to grant interlocking letters to obtain an effective date for the H1B Visa. The effective date of the Visa will be the effective date of the Louisiana license or permit issued by the LSBME.
• The applicant’s employer usually needs a valid LSBME license to complete the credentialing process for hospitals, insurance companies, and professional liability insurers. Therefore, the licensure applicant should work with the United States INS Visa sponsor to set the effective date for the Visa.

Marriage Certificate/Name Change
Application for licensure in a name other than what appears on the birth certificate requires a notarized copy of official documentation of name change (ie marriage certificate).

Notarization as a “true copy”
Request the notary to certify a copy of your birth certificate and/or marriage certificate as a “true and correct copy of the original”. If the notary will not certify the document, you can attest that it is a “true and correct copy of the original”. The notary can then notarize your signature.

Verification of Licenses in Other States
Verification of state licenses are required. Contact the state board(s) directly to obtain verification of your license. Please note, there may be a processing fee needed.

Other Information

Verification of Application/Licensure Status
Visit our website www.lsbme.la.gov and log on to your account to verify the progress/status of your application.

Communication with the Board
Mailing Address - LSBME, 630 Camp Street, New Orleans, LA 70130
Questions - Contact our licensing department at licensing@lsbme.la.gov. To find the analyst directly assigned to your application, click on Contact Us.

Contact Addresses

Federation of State Medical Boards, Inc. (FSMB)
400 Fuller Wiser Road, Suite 300
Euless, TX 76039-3855
(817) 868-4000
Website: www.fsmb.org

Educational Council for Foreign Graduates (ECFMG)
3624 Market Street, Fourth Floor
Philadelphia, PA 19104-2685
(215) 386-5900

The National Board of Medical Examiners
3750 Market Street
Philadelphia, PA 19104-3102
(215) 590-9500

The National Board of Osteopathic Examiners, Inc.
8765 West Higgins Rd, Suite 200
Chicago, IL 60631-4101
(773) 714-0622

American Board of Medical Specialties
1007 Church Street, Suite 404
Evanston, IL 60201-5913
(847) 491-9091

Louisiana State Board of Medical Examiners
630 Camp Street
New Orleans, LA 70130
(504) 568-6820