Visas and Licensure

Click below to jump directly to the article:
How to Practice Neurosurgery or Neurology in the USA
All About Visas
J-1 Visas & Waiver Information
Everything You Wanted To Know About the O-1 Visa
State Licensure Requirements
Federal Credentials Verification Service
California Licensure
Florida Licensure
Texas Licensure

How to Practice Neurosurgery or Neurology in the USA

If you are a physician who has completed training in a country other than the USA or Canada, and you would like to find a job in the USA, there are several steps you need to complete.

1. USMLE (United States Medical Licensure Exam) Step One (for applications and requirements, see: www.usmle.org ). 
   1. To be eligible for the USMLE, your medical school and year of graduation must be listed in the IMED (International Medical Directory). Medical school programs shorter than 4 years are not acceptable. See: http://imed.ecfmg.org/search.asp .
   2. You must apply with the NBME (National Board of Medical Examiners) for the USMLE. The application instructions and form are here: https://external1.nbme.org/ciw/servlet/candidate_menu . 
2. USMLE Step 2 CK (Clinical Knowledge)
3. USMLE Step 2 CS (Clinical Skills)
   1. Beginning in 2004, this is a new Step 2 test that incorporates 2 other tests, eliminating the need for them � the TOEFL (Test of English as a Foreign Language) and the CSA (Clinical Skills Assessment). 
   2. This test combines an examination of clinical medical skills and English Language proficiency (written and spoken).
4. Apply for your ECFMG Certificate . See: www.ecfmg.org . Requirements:
   1. Must have passed the USMLE's
   2. Must have your application signed within 4 months of submission by an official at your medical school stating that you graduated.
   3. 2 diplomas and 2 pictures of yourself
   4. Final medical school transcript
5. Apply for your Internship or Transitional Year (PGY-1) at an accredited residency program in the USA. For neurology, the internship is usually in Internal Medicine. For neurosurgery, the internship is usually in General Surgery.
   1. See:  http://www.nrmp.org/res_match/index.html ; http://www.nrmp.org/res_match/about_res/univappl.pdf ;  http://www.aamc.org/students/eras/start.htm
6. Once you have been accepted to a program, you must apply for your J-1 Visa . (If you have the possibility of obtaining a better visa or a green card, by all means, do so.) You must:
   1. Hold a contract or an official letter of offer for a position in a program of graduate medical education or training that is affiliated with a medical school;
   2. Provide a statement of need from the Ministry of Health of the country of nationality or most recent legal permanent residence. This statement must provide written assurance that the country needs specialists in the area in which the Exchange Visitor will receive training. It also serves to confirm the physician's commitment to return to that country upon completion of training in the United States (as required by §212(e) of the Immigration and Nationality Act as amended). (Note: If permanent residence is in a country other than that of citizenship, the Ministry of Health letter must come from the country of last legal permanent residence.)
7. In your PGY-1, you need to apply for a Residency Program .
   1. To enter a Neurology Residency program, the American Board of Psychiatry & Neurology requires that your medical school be listed by the World Health Organization. See: http://www.who.int/hrh/documents/HRH_documents/en/index1.html . 
   2. For Neurology & Neurosurgery, you must apply to the SF Match. For complete instructions, see: http://www.sfmatch.org/
   3. You must also check the requirements of the programs themselves. For more info, see: http://www.ama-assn.org/ama/pub/category/2997.html . 
8. Once accepted to a Residency Program, you need to apply for State Licensure . For info on applying for state licensure, see: http://www.fsmb.org/members.htm . 
9. After residency, you can:
   1. Apply for Fellowship Programs � see:
      1. Neurology: http://www.aan.com/students/awards/fellowship.cfm
      2. Neurosurgery: http://www.sfmatch.org/fellowship/f_neurosurgery/index.htm or
      3. Neurology or Neurosurgery: http://www.ama-assn.org/vapp/freida/srch/
   2. Find a Job . See All About Visas .

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All About Visas

What every International Medical Graduate (IMG) must do to practice in the United States:

1. Must have a degree from a foreign medical school.
2. Must pass the USMLE (US Medical Licensing Exam) Parts I & II.
3. After doing all of the above, the physician must obtain an Educational Commission on Foreign Medical Graduates (ECFMG) certificate showing the physician has knowledge equivalent to that gained in a U.S. medical school.
4. Must complete a residency in a US residency program, even if they did a residency in their home country.

The J-1 Visa Waiver

The J-1 Visa Is issued to students to permit them to reside in the USA while they are enrolled in school. After graduation, the physician must return to their home country for two years. They are ineligible to apply for H1B sponsorship.

In order to remain in the USA instead, the physician must obtain a J-1 Waiver. There are 3 routes to obtaining the J-1 waiver.

1. If the applicant can demonstrate that he or she will suffer from persecution in his or her home country or country of last permanent residence;
2. If fulfillment of the residency requirement would bring proven exceptional hardship to the applicant's spouse and/or children who are U.S. citizens or permanent residents;
3. If the applicant is sponsored by an interested governmental agency (IGA) which is interested in the physician's continued employment in the U.S.

Waivers for the first two reasons are extremely rare. Most IMG's obtain waivers through the IGA method. The main agencies which can obtain waivers for them are: the US Dept. of Health & Human Services, the Veteran's Administration, the Dept. of Agriculture (rural positions), the Appalachian Regional Commission (ARC), and the Conrad State 20 (state dept's of health). 

What the agency or Health Professions Shortage Area (HPSA) facility must do to obtain a visa waiver for an IMG:

1. The head of the health care facility that will employ an IMG must affirm that the facility is physically located in a designated HPSA, or Medically Underserved Area (MUA). Typically, the locations are very rural or inner city hospitals.
2. The IMG must sign a statement declaring that he or she does not have more than one J-1 waiver request pending at the same time.
3. No contract may have a "non-compete" clause.
4. The J-1 waiver is limited to physicians who practice in primary care, defined to be general or family practice, general internal medicine, pediatrics, psychiatry or obstetrics and gynecology.

The H-1B Visa

Update: For FY 2009, USCIS announced on April 8, 2008 that the entire quota for visas for the year has been reached, for both 20,000 Advanced and the 65,000 quota. USCIS would complete initial data entry for all filing received during April 1 to April 7, 2008 before running the lottery.

The annual cap on this temporary work visa now stands at 85,000 per year. (This includes the 20,000 slots for those possessing a master's degree or higher.) For FY 2008, the entire quota was exhausted before the end of the first day on which applications were accepted, April 2nd, 2007.  The additional 20,000 Advanced Degree H-1B visas for FY 2008 was exhausted on April 30, 2007. The H-1B is an employer-sponsored visa that allows foreign professionals to work in the U.S. for 3 years with one 3-year extension allowed. At the end of that time, IMGs must leave the U.S. for one year, unless they have obtained permanent residence (a green card) or have obtained another type of work visa. An increasing number of IMGs enter the U.S. on H-1B visas in order to enter their residency programs, with the residency programs acting as the "employer." 

Exempt from the cap:

• Universities
• Government-sponsored research institutions
• Current H1B holders
• H1B holders who are transferring to another H1B sponsor
• H1B holders who are applying for their 3-year extension

What the Physician must do to obtain an H1B visa:

1. Must have fulfilled any J-1 visa requirements.
2. Must complete USMLE Part III.
3. Must obtain licensure in the state of intended employment.
4. Find an employer willing to sponsor him/her and have a signed contract from the employer. Many IMG's are getting an H1B from the residency program, with the residency program acting as their �employer,� and then transferring their H1B to a new employer after residency. However, the process is the same as applying for a new one, except it is not subject to the quota.

H1B's spouse (and children) are entitled to the H-4 (dependent) visa, under which they cannot work in the United States. This can cause stress to qualified spouses of the H1B holders. Some of them wait in queue for years to get their own H1Bs. In contrast, L-1 dependent visa holders (L-2) can work, if their EAD is approved by USCIS. The process takes about 3 months, and costs are around $400.00.

What the Employer must do to obtain an H1B visa for a Physician:

1. If the employer is "H1B Dependent," they must advertise the position in the USA prior to petitioning to employ H1B workers for those positions.  "H1B Dependent" is defined as having H1B holders composing over 15% of the employer's workforce.
2. File a Wage Determination Form with the DoL to ensure that the employer is paying the �prevailing� wage.
3. File a Labor Condition Application (LCA) with the U.S. Department of Labor. In this application the employer must certify that they are paying the prevailing wage; working conditions will not adversely affect the working conditions of US Citizens; and that the place of employment is not experiencing a labor dispute involving a strike or blackout.
4. File the I-129, I-129W and H Supplement with the INS.
5. File a specialty petition with the INS with proof that the position requires highly specialized knowledge. This petition cannot be filed until the employer has the LCA approved. Must also file physician's licensure and degree certifications, plus the employer's contract with the physician.
6. Once these steps are completed, the employer must file an H-1B petition with the U.S. Immigration and Naturalization Service (INS). In the past, the time frame to obtain an H-1B has been about 60 days, plus the time it takes for the physician to obtain a state license. Now, however, we are reaching the annual cap on H-1B visas earlier and earlier.
7. In the event that the employer terminates the employment of the IMG prior to expiration of the H-1B visa, the employer is responsible for providing return transportation of the physician to his or her last place of foreign residence.
8. Once the H1B has expired after 6 years, the H1B holder must return to his/her country of residence for one year before becoming eligible for another H1B visa.

Other Types of Visas

• L-1 visas are issued to foreign employees of a corporation.  The employee must have worked for the corporation for one year in the preceding three years prior to relocating to the USA. 
• TN-1 (NAFTA) visas are issued to Canadian and Mexican physicians, but are currently limited to teaching or research only.
• E-3 visas are issued to Australian citizens under a free-trade treaty.
• H1B1 visas are issued to citizens of Chile and Singapore under a NAFTA treaty.
• O-1 visa - see article below.

Permanent residence (the green card)

Update: In-house recruiters are now telling us that in the past only 8% of H1B's applying for Green Cards were rejected; however, as of 2006, 50% are being rejected. Please pursue all other avenues towards getting a work visa!

The H1B visa is considered "dual-intent."  This means that H1B holders are permitted to apply for a green card. 

H1B visa holders may be sponsored for their green cards by their employers through an Application for Alien Labor Certification, filed with the U.S. Department of Labor.  The sponsorship process can take several years, and for much of that time the H1B visa holder can be unable to change jobs without losing their place in line for the green card. Since the duration of the H1B visa hasn't changed, this has meant a lot more H1B visa holders have to renew their visas in 1 year or 3 year increments to continue to be in legal status while their green card application is in process. If the physician has applied for their green card prior to their 5th year of employment, they may be entitled to 1-3 year extensions of their H1B visa

There are several avenues IMGs can take to obtain a green card. A standard approach is called "Labor Certification" through "Reduction in Recruitment." This is the process in which the employer must actively recruit for the job for six months and must advertise for the position in a major national publication such as The New England Journal of Medicine or Journal of the American Medical Association. While the time to complete labor certification has decreased, INS processing is still slow, so obtaining a green card can take years.

This is an important point to consider if the employer is attempting to obtain a green card for an IMG currently on an H-1B. Will the IMG's H-1B expire before a green card can be obtained? If so, the employer may wish to pursue a faster method of obtaining a green card.

One expedited method for obtaining a green card is through a "National Interest Waiver," which does not require employers to go through the labor certification process. Instead, they must show that their communities historically have had a difficult time recruiting physicians. Generally, employers must be in a Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA) to obtain a National Interest Waiver on behalf of an IMG. Congress and the President recently restored the ability of certain physicians to obtain National Interest Waivers. In addition, an IMG might qualify for a green card through a U.S. relative, through the visa lottery, or other possible channels.

Canadian Physicians

What Canadian physicians must do to work in the USA:

1. Canadian physicians do not have to complete a residency in the USA.
2. Despite the fact that over 40 states recognize the Canadian medical licensure exam as the equivalent to the US one, the US federal government still requires that they take the USMLE's
3. They then can try to get an employer to sponsor them for an H1B, the process is the same except for the fact that getting state licensure is easier for them.
4. Canadian residents are eligible for a special "L" visa.  We do not currently have much info about that type of visa.
5. TN-1 (NAFTA) visas are issued to Canadian and Mexican physicians, but are currently limited to teaching or research only.

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J-1 Visas & Waiver Information

With rare exceptions, none of the employers that have contracted with MedHIRE, LLC are willing to accept J-1 visa holders. We strongly recommend pursuing the following options:

• Hire an immigration attorney to explore all your options.
• Try to find a position through the National Rural Recruitment & Retention Network at http://www.3rnet.org/index.asp .
• Try to find a position with a VA hospital at http://www.vacareers.com/index.cfm .
• Try to find a position with the Appalachian Regional Commission at http://www.arc.gov/index.do?nodeId=24 or call (202) 884-7680.
• A law firm has a free list of Conrad State 20 contacts. See http://www.shusterman.com/conrad20.html . (This does not constitute an endorsement of said law firm.)
• There may be J-1 waiver positions available through the US Department of Housing and Urban Development (HUD). Call (202) 708-0030.
• The National Institutes of Health (NIH) is granting J-1 visa waivers only to those individuals involved in research of national and/or international importance. You may contact NIH at (301) 496-6166.
• The US Department of Agriculture has withdrawn from IGA status and the J-1 waiver program. Instead this is now handled by the US Department of Health & Human Services - (301) 443-3376.
• Some practices are able to sponsor H1B visas, if they can prove that efforts to recruit American physicians have been unsuccessful for a long period of time. We have noticed that the amount of practices willing to do so has severely declined since 9/11. This is probably due to the increased time length of the process and the increased risk for the employer. As of January 2006, we are hearing that H1B's who apply for a green card are experiencing a 50% rejection rate from the INS.
• In general, the employers who are able to accept J-1 visa holders do not work with outside recruitment agencies, such as MedHIRE, the reason being that they have little difficulty finding and obtaining candidates on their own.
• We have found positions for H1B and O-1 visa holders (who have fulfilled their J-1 requirement or obtained a J-1 waiver), so if you acquire either type of visa, contact us when you are available to look for a position. However, H1B holders must be completely open to where they are willing to locate. Please note that as stated above, H1B holders are having an increasing difficult time acquiring a green card.
• There is a light at the end of the tunnel. Physicians who have obtained their waiver in one of the above ways, worked for the required term (usually 3 years), and have a green card or other permanent work visa lined up are very much in demand and sought after by MedHIRE employers.

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Everything You Wanted To Know About the O-1 Visa

Update: We are hearing that the timeline for obtaining an O-1 visa has increased to 3 years!

The O-1 visa is a temporary work visa available to those foreign nationals who have "extraordinary ability in the sciences, arts, education, business or athletics" which "have been demonstrated by sustained national or international acclaim." The person entering the US must be coming to work in their field of ability, but the position need not require the services of a person of extraordinary ability. Extraordinary Ability in Science, Education, Business or Athletics.

To obtain an O-1 visa to work in the sciences, education, business or athletics, applicants must demonstrate that they possess "a level of expertise indicating that the person is one of the small percentage who have risen to the top of the field of endeavor." There are two ways to demonstrating this expertise. One method is through receiving a major internationally recognized award such as a Nobel Prize. The more common way is by providing documentation in three of the following categories:

• Receipt of nationally or internationally recognized prizes or awards for excellence in the field of endeavor
• Membership in associations in the field which require outstanding achievements of their members
• Published material about the alien
• Participation as a judge of the work of others in the same or allied fields
• Evidence of original contributions of significance in the field
• Authorship of scholarly articles
• Evidence of employment in a critical or essential capacity for organizations with a distinguished reputation
• Evidence that the alien has or will command a high salary

Comparable evidence that does not fit within these categories may also be submitted.  

Consultation Requirement
Before a person will be granted either an O-1 or O-2 visa, the INS requires a consultation with a US-based organization.  

The petition must include an advisory opinion from a peer group, labor union, or person with expertise in the applicant's field. This opinion can either state simply that the group has no objection to issuing the visa, or can detail the applicant's achievements. If the achievements are detailed, the letter should also address the applicant's ability, the nature of the position offered, and whether the position requires a person of extraordinary ability.  

If the consultation is with an organization other than a labor union, the INS will forward the application to the union it deems appropriate within five days of receiving the petition. The union must issue an opinion on the petition within 15 days, and then the INS has two weeks to rule on the application.  

Applying for an O-1 Visa
An alien cannot apply for an O visa in his or her own name. They can, however, file through a US agent. The petition should be filed at the regional service center with jurisdiction over the US agent. If the petitioner is a foreign employer, the application should be filed at the regional service center with jurisdiction over the location of the first place the beneficiary will work.  

The form for petitioning for an O visa is the I-129. This must be submitted along with the consultation opinion, evidence documenting the alien's extraordinary ability, and details of the proposed work in the US. The petition is to be approved for a maximum of three years.

An O visa may be extended in one-year increments for an indefinite period of time. Form I-129 is also used to file for an extension. The application for an extension does not need to include a consultation, and requires only a statement of why the extension is sought.

Finally, O visas are what are known as "dual intent visas", meaning that even though the applicant has filed a labor certification or petition for classification as a preference worker leading to permanent residence, the O visa cannot be denied.

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State Licensure Requirements

In most states, acquiring a license takes anywhere from 3-6 months.

States that are notorious for a lengthy process of 6 months to one year are California, Florida & Texas.  (See additional info about their processes below.)  What this means is that these states are currently glutted with physicians and are trying to discourage more physicians from relocating to them.

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Federal Credentials Verification Service

The FCVS - Federation Credentials Verification Service is a division of the Federation of State Medical Boards (FSMB) based in Dallas, Texas. In the 1990's Congress authorized the set up of the FCVS service as a alternative to primary source credentialing for a Physician's Core Credentials. The idea was to create a repository of the Doctor's Training Certificates and Documents so that the Licensing / Credentialing process would be streamlined by eliminating the need to continually go back to the Medical School and Internship/Residency/Fellowship programs over and over again each time the Physicians Core credentials were required to be verified. How does this work?

A Physician who is required to use FCVS by a State Medical Board, (Maine, Kentucky, Ohio, New Hampshire, Rhode Island, Minnesota, and Utah - For All Doctors   & New York for Foreign Trained Doctors), or who desire to utilize this service is required to submit the FCVS application online or in paper form to the FCVS. Along with the application a sizeable fee ($300- $500), an Original Birth Certificate / Original Passport, Copies of the Medical School Diploma, PGT Certificates, Name Change Documentation, Board Certification Certificates, Transcripts, and ECFMG Certificate (if applicable) are sent to the FCVS. 

Once these items are received the FCVS will take 30 days to send out their first request to the Medical School and all Post Graduate Training (both Foreign and Domestic). If these institutions do not complete the process within 30 days another request is sent. (Ideally). If the second request isn't received by the FCVS, then another request is sent 30 days later. This continues until the minimum number of request have been processed by the FCVS (varies by State Board - 3 to 7 request). Once the minimum number of request has been attempted then FCVS will forward the packet to Q/A - Quality Assurance. Here the file will sit for 2 to 4 weeks while Q/A verifies the completeness of all documents. If nothing is missing then the file is Federal Expressed to the Recipient/State Board of the Physician's choice. 

This entire process will take 3 to 12 months depending on the State Medical Board and the Doctor's background. 

The Pros of the service are straightforward. If a Doctor is foreign trained then it is invaluable to have the Medical School Records on file with the FCVS so that the Physician will not have to go back to the Medical School each time this credential has to be verified. 

The Cons are as follows.

1. Using FCVS will extend the licensing time by 2 to 10 months if it is your initial request/set up.
2. FCVS re-verifies all Internships/Residencies/Fellowships each time a Doctor requests that his/her packet be sent to any State Medical Board or Institution. This defeats the reason/purpose for utilizing the FCVS service to begin with.
3. USA Trained Physicians can have their training verified in 2 to 6 weeks if they handle the verification process themselves or hire a licensure expediting firm . Compare this to FCVS (3 to 12 months on first request and 2 to 4 months on each subsequent request) and it doesn't make sense for Domestic Doctors to utilize the FCVS service unless they are planning on licensing with more then 10 State Medical Boards at one time.

Most Boards accept the FCVS Service. We have included a Directory of the States from the FCVS website below which provides information as to which States accept FCVS and which do not.

Medical and Osteopathic Licensing Boards that Accept the

FCVS Physician Information Profile

1. Requires FCVS Profile for all applicants for licensure (*-Minnesota, New York, non-LCME or AOA accredited or board approved).
2. Requires verification of postgraduate training performed in England, Ireland and Scottland
3. Requires FMGs seeking licensure by endorsement to have an existing license from another U.S. jurisdiction.

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California Licensure

The California Medical Board has a reputation for being one of the most difficult State Medical Boards in which to obtain a license. The Medical Board of California requires that each Physician submit a set of Fingerprint cards or travel to California to participate in the LiveScan process. It is highly recommended that the Physician travel to California to complete the LiveScan process instead of submitting Fingerprint Cards. Why? Fingerprint cards take 2 to 4 months to process. The license will not be issued until the report is returned to the Medical Board of California by the FBI. 10 to 25% of the Cards are rejected by the FBI because the prints are smudged, low quality, or indistinguishable. If this happens then new cards have to be submitted and the process is extended another 2 to 4 months. However with the LiveScan process, the report is returned to the Medical Board of California 3 days after the Scan takes place.

Once the application is submitted to the Board and the Verifications have been requested, the Doctor can only wait until 45 to 60 business days have passed before contacting the State Board. The Medical Board of California has a strict policy against contacting the Board prior to this waiting period. With most physicians, once a reviewer is assigned to the application, then the license is issued 5 to 10 days later. In the event that a verification is rejected , lost (by the USPS or Medical Board of California) while in transit, or never received by the Medical Board of California, then a letter is sent to the Doctor detailing what items are still needed. Foreign Trained Doctors who completed Clinical Clerkships in the USA during their fourth or fifth year have additional delays because each Clinical Clerkship has to be verified by the Department of the Clerkship. Most hospitals do not have records of these clerkships and thus the process is considerably delayed by the California requirement. 

The real con to the Medical Board of California's licensure process is there is a lack of recourse when it comes to the decisions of the Boards. It seems that the Board has the ability to reject/deny an application based solely on the opinion of the reviewer for any negative found in the Doctor's file. Typically no hearing is required and the rejection can be arbitrary. Once a rejection is issued there seems to be little or no recourse to remedy the problem in the courts. If a Physician has a clean history, the California will be a smooth process with licensure times that rank among the fastest in the Nation. If there are negatives in the Physician's background then the process will be extended and could be problematic.

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Florida Licensure

Of all the Boards in the United States, Florida presents one of the most difficult application processes. The term in which it takes for a physician to obtain a license in Florida will vary between 3 to 6 months depending on the Physician's work experience, educational training and past issues. Florida does present its' own unique issues which must be addressed by the Physician.

Florida is the most expensive board for a Physician to apply. Behind the Florida Medical Board are California, New Jersey, Texas, and Nevada. The totality of fees going to Florida is $1192.00.

The Florida Department of Health also requires Fingerprint Cards. Because of this the process can be artificially delayed by 3 to 12 weeks. The Cards are sent to the Florida Department of Law Enforcement to be processed. If there is a backlog on their cases delays can be expected. The Board holds the cards typically a week to 4 weeks after the application is received. Then they are sent to FDLE. The application will not be presented to the Board until the results of the Criminal Background search are received. If for any reason the cards cannot be read by the FDLE then the cards are rejected. If this happens then a new set of cards are send to the Physician to have reprinted and the process repeats itself again. This will add another 4 to 12 weeks to the licensure time. A larger percentage of horror stories with Florida concerning extended licensure periods are usually caused by rejected prints. It is recommended that before a physician has the cards printed at a law enforcement agency that they apply "Corn Husker's Lotion" to their hands 3 times a day for a minimum of 7 days in advance of the printing. Corn Husker's Lotion helps to build up the ridges on the finger pads, which are worn down from, continued washing. It is also recommended that the Physician seek and find a printing facility with offers "Electronic Printing". This is a process where the fingers are scanned on a scanner and then the prints are printed onto the finger print cards. This will help to avoid smudging and thus increase the probability that the cards will be adequately read by the FDLE.

Unlike most other Boards, Florida verifies the Physician's Internships, Residencies, and Fellowships along with the Physician's Privileges directly. The Physician and/or Licensure Company are not involved in this part of the process. Unfortunately for the Physician, Florida mails out one request to the GME Office and Staff Office of the Hospital in question and then leaves it to the Hospital to follow through with their request for verification of the issue in question. Quite frequently the forms never reach the proper person or department and thus the physician's application is never completed. A licensure expediting agency can be utilized to actually follow up with the GME Office and Staff Offices once the first deficiency notice is delivered to the Doctor. A licensure expediting agency can verify all contact information and then forward it directly to the Analyst at Florida with a request that they re-send the form to the corrected contact. Then they follow up with each GME and Staff Office until they have confirmed that the forms have been mailed to Florida.

The most ominous issue with the Florida Board of Medicine is the accuracy requirement concerning the content of the application. Simple mistakes on the application by the Physician will result in the Physician being ordered to appear before the Florida Board and thus guarantee a fine of $500.00 and up. Most fines run between $1000.00 to $5000.00. For multiple mistakes or omissions fines can increase to $10,000 to $50,000. These fines are generally not considered disciplinary in nature and do not go on the Physician's permanent file. They are more revenue generating in nature. Florida does not have an income tax and thus raises revenue through tolls, fees, and fines. Once an error or omission is found by the Florida Board during the application process the doctor will need to be prepared to make travel plans to Florida.

The Board Members of the Florida Board typically approve most applications with errors and omissions. If they believe the Doctor was being deceptive then a denial can be issued. This is the worst case scenario for a physician. A Denial from One State Board has a ripple effect on all the other State Boards in which the Doctor is licensed by or applying to. At renewal the Physician will have to answer to his licensed boards as to why he was denied by the Florida Board. Many Boards will reciprocate with Florida and take action against the doctor.

Florida offers many challenges and obstacles to the Doctor. The key with Florida is for the Doctor to insure that his/her application is 100% accurate before it is submitted to the Board. If the Physician does not take time to insure that his/her information is correct then the Physician will be bringing problems upon him/herself in the months following the submission of the Florida Medical Application.

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Texas Licensure

The Texas process is one of the most lengthy licensure processes in the 50 States. Most applicants can expect a 4 to 6 month process to occur before the license is issued. Foreign Medical Graduates will have to wait even longer. Why? The reason for the length is due to the Texas process. All applications have to go through two different reviews. The first occurs once the application and all verifications are received by the Screen-CIC department. CIC clears the application to be assigned to a Licensure Specialist on the Texas Board. It typically takes 4 to 8 weeks to have all of the verifications forwarded to the Texas Board. Once all have been received then the application is then forwarded to the Licensure Specialist. The Licensure Specialist will then review the verifications to determine if they are properly completed by the third party. The Specialist typically will find one or two that are not properly completed and thus will require that the third party complete them again. At the same time the doctor is instructed to set up and take the Jurisprudence Examination. It typically takes 2 to 4 weeks for the application to be cleared by the Specialist if everything is in order. Once the Specialist clears the application then the doctor is notified that he/she will have to travel to Austin, Texas for a personal interview. After the interview, the application is then submitted to the full Medical Board for approval. The Board meets once every two months. If the Board does not have time to discuss your application, then your licensure is further delayed for an additional 2 months. In our experience, this has happened with some applicants 2 or 3 times. The process listed above entails everything being completed without any issues, mistakes, or errors.

Texas does offer a Temporary Permit once the application clears Screen-CIC. This is the only silver lining in the clouds. This occurs at the 4 to 8 week mark with most applicants. 

The Jurisprudence Examination is a formal exam which does require some preparation by the Doctor. TSBME does offer two study guides on their Web Store, yes they have a web store where you can buy Texas Medical Board T-shirts and coffee mugs. These guides aren't cheap. You will drop 200 to 500 dollars on them. The examination is proctored by Prometrics.com in most metropolitan areas. If you fail the examination 3 times then the board will clear you at the next board meeting.

Texas has a 3 attempt limit on the USMLE for each Step. They also have a 7 year limit on the passing of all three steps. It is 10 years if you are board certified.

If you haven't taken a Board Specialty Examination  ( www.abms.com ) in the past 10 years or a written board examination, SPEX, USMLE, LMCC, then you will be required to pass the SPEX examination.

Foreign Medical Graduates are required to provide a copy of their license certificate from the country in which they graduated. If they cannot provide this then a letter must be obtained from the licensing board in the country of their graduation demonstrating their eligibility to be licensed. This is no easy matter for many of the countries in question.

Texas ranks as one of the most difficult boards to license. The staff members at the Texas Board are very helpful but the process itself creates the problems. Everything with Texas is verified. Mississippi and Arkansas are the only Boards which exceed Texas' verification process. Our advice to any physician planning on applying to Texas is that you should give yourself a lot of time to have the process completed. If not you might find yourself in Texas with a lot of time on your hands while the process works itself out.

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