The L For Texas Medical Board form is a crucial document required for the licensure evaluation of physicians in Texas. This form verifies postgraduate training and professional history, ensuring that all applicants meet the necessary standards to practice medicine safely. If you are ready to begin your application process, please fill out the form by clicking the button below.
The L For Texas Medical Board form, formally known as the Physician Licensure Evaluation, plays a crucial role in the licensure process for medical professionals in Texas. This form is essential for applicants seeking to verify their postgraduate training and professional history. As part of the application, candidates must provide detailed information about their affiliations with medical facilities over the past five years, including the names of institutions, positions held, and dates of training. Evaluators, typically high-ranking physicians such as Chief of Staff or Medical Directors, are responsible for completing a section of the form that assesses the applicant's professional conduct, competence, and overall character. Importantly, this evaluation is not just a mere formality; it involves a thorough review of the applicant's training history and any unusual circumstances that may have arisen during their medical education. Confidentiality is paramount, as the information collected is protected under Texas law, ensuring that sensitive details are handled appropriately. The form also includes sections for evaluators to report any concerns regarding the applicant's professional behavior or qualifications, making it a comprehensive tool for assessing readiness to practice medicine safely and effectively.
FORM L
Physician Licensure Evaluation – Texas Medical Board
Verification of Postgraduate Training and Professional Evaluation
APPLICANT: Complete the information in this box.
Full, Admin, Conceded Eminence, or Physician-in-Training Applicants: You must have evaluations from every facility with which you have been affiliated in the past 5 years. Note – your licensure analyst may require additional evaluations outside the past 5 years.
Provisional License or Physician Graduate Applicants: You must have evaluations from every facility with which you have been affiliated in the past 2 years. Note – your licensure analyst may require additional evaluations outside the past 2 years.
Applicant’s Current Full Name: ____________________Applicant TMB ID# _________________
Applicant’s Date of Birth: ____________________
Name of Evaluating Hospital/Institution _________________________________________________________________
Address of Evaluating Hospital/Institution _______________________________________________________________
Dates of affiliation From (mm/yy) ______________________ To (mm/yy) ______________________
Department of Affiliation__________________________________
Your position at the time of affiliation: Intern Resident Fellow Faculty Staff Other: ___________
I hereby authorize all hospitals, institutions or organizations, my references, personal physicians, employers (past, present and future), business or professional associates (past, present and future) and all governmental agencies (local, state, federal, or foreign) to release to the Texas Medical Board or its successors any information, files or records, including medical records, educational records, and records of psychiatric treatment and treatment for drug and/or alcohol abuse or dependency, requested by the Board in connection with this application, necessary to determine my medical competence, professional conduct, or physical and/or mental ability to safely engage in the practice of medicine. I further authorize the Texas Medical Board or its successors to release to the organizations, individuals, or groups listed above, any information, which is material to this application, or any subsequent licensure.
I authorize the release of the information contained in this evaluation form to the Texas Medical Board.
___________________________________________________
Applicant’s Signature
EVALUATING PHYSICIAN:
•A physician who currently holds one of the following positions must complete this evaluation: Chief of Staff, Department Chairman, Medical Director, or Training Director. Letters of recommendation or standard institution verification forms will not be accepted in lieu of this form.
•This completed evaluation should be sent directly to the Texas Medical Board offices via mail, fax, or email.
▪By mail - Place this form in an envelope of the hospital/institution that you represent, seal the envelope and place your signature over the outside sealed envelope flap. Send to: Texas Medical Board, MC-240, P.O. Box 2029, Austin, TX 78768-2029
▪By fax - Evaluator must submit the form along with an official hospital/institution coversheet to 888-550-7516. Fax submitted by the applicant and/or without the appropriate coversheet cannot be accepted.
▪By email - Evaluator must submit the form from an official practice/institution email address to screen- cic@tmb.texas.gov. Emails sent from the applicant cannot be accepted. Only files attached as .pdf or .tif can be safely opened and drop boxes, secured emails, encrypted messages, or links to outside sites cannot be accepted.
This is important: All information on this Form L, (including attachments that you provide as the Evaluating Physician) regarding a licensure applicant is confidential pursuant to §164.007(c) of the Medical Practice Act. However, the Board must provide a copy of this Form L and attachments to an applicant when an application is referred to the Licensure Committee for licensure determination. Any information furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity from Civil Liability.
FOR TRAINING POSITIONS – Completion of the Verification of Post Graduate Training on page 2 and the Verification of Professional History on page 3 are required.
FOR NON-TRAINING POSITIONS – Only completion of the Verification of Professional History on page 3 is required.
Form L Physician Licensure Evaluation
Version 01.2026
Applicant's Name___________________________________________
Page 2
Printed
VERIFICATION OF POST GRADUATE TRAINING
Only post-graduate training completed at this institution should be evaluated in this section.
PGY: _______
Department: _________________________________
From: ___/___/___
To: ___/___/___
POST GRADUATE TRAINING
___ Internship
PROGRAM PARTICIPATION:
___ Residency
Credit received?
Full
*Partial
in progress
Report incomplete postgraduate years
___ Fellowship
*For partial credit– how many months?______
___ Research
(PGY) separately from those that were
successfully completed.
If the postgraduate year is currently in
progress, report the expected completion
date in the “To” field.
UNUSUAL CIRCUMSTANCES: (For training positions only)
Yes No 1. Did this individual ever take a leave of absence or break from training?
Yes No 2. Did this individual resign from training?
Yes No 3. Were any limitations or special requirements placed upon this individual for professionalism or behavioral issues?
Yes No 4. Did this individual ever receive a written warning or documented counseling about his/her behavior?
Yes No 5. Was this individual ever placed on probation for any reason?
Yes No 6. Is this individual currently under investigation?
Yes No 7. Were this individual’s privileges or duties ever reduced, suspended, or revoked?
Yes No 8. Did this individual experience delayed promotion or delayed advancement to the next level?
Yes No 9. Was this individual informed his/her contract would not be renewed?
Yes No 10. Was this individual suspended, terminated, or dismissed from training?
If you answered "yes" to any of the above questions, please provide any additional information you may have.
Page 3
VERIFICATION OF PROFESSIONAL HISTORY
1. This evaluation is based on Personal Knowledge
Review of Credential File
2.Is this applicant related to you? Yes No
3.Do you consider the applicant:
(a) Reliable?
Yes
No
(b) Ethical?
(c) Of good character?
4.Please rate the applicant:
(a)Professional ability
(b)Attention to duties
(c)Breadth of education
(d)Interpersonal skills
Excellent
Good
Average
Poor
5.Has applicant, to your knowledge, ever been guilty of:
(a) Fraud or dishonesty?
(b) Unprofessional conduct?
6. To your knowledge, has the applicant ever:
(a) been warned, censured, reprimanded, disciplined, had admissions monitored or privileges limited
or suspended?
Yes
No
(b) had disciplinary action taken against him/her by a licensing agency?
(c) been denied or surrendered a federal or state controlled substance permit?
(d) been arrested, fined, charged with or convicted of a crime, indicted, imprisoned
or placed on probation?
(e) been a defendant in a legal action involving professional liability (malpractice) or had a
professional liability claim paid in his/her behalf or paid such a claim him/herself?
(f) been placed on probation, asked to withdraw, or reprimanded?
(g) been terminated, resigned in lieu of termination or during investigation?
If you answered "yes" to any of Question 5 and/or 6, please provide any additional information you may have, including the names of other individuals who may have information concerning this applicant.
7.Provide dates of affiliation: Beginning month ______ / year _______ Ending month _______ / year _______
Evaluating Physician’s Name/Degree:
Title:
Chief of Staff
Department Chair
Medical Director
Training Director
Phone:
Fax:
Address:
Email Address:
Signature:
Date:
Filling out the L Form for the Texas Medical Board is a crucial step in the licensure process. This form requires detailed information about your postgraduate training and professional evaluations. Completing it accurately and thoroughly will help streamline your application and avoid potential delays.
Once the form is completed, it should be sent directly to the Texas Medical Board via mail, fax, or email, as specified in the instructions. This submission will help facilitate the evaluation process and move you closer to obtaining your medical license.
The L For Texas Medical Board form is designed to evaluate a physician's postgraduate training and professional history. It is a crucial part of the licensure application process in Texas. This form must be completed by the applicant and submitted along with evaluations from every facility with which the applicant has been affiliated in the past five years. The Texas Medical Board may require additional evaluations beyond this timeframe, depending on the applicant's specific circumstances.
The evaluation section must be completed by a physician who holds a significant position such as Chief of Staff, Department Chairman, Medical Director, or Training Director at the evaluating institution. It is important to note that letters of recommendation or standard verification forms cannot replace this specific evaluation form. The completed evaluation must be sent directly to the Texas Medical Board via mail, fax, or email from the evaluating physician's official institution.
The applicant must provide their current full name, date of birth, Texas Medical Board ID number, contact information, and details about their affiliations with evaluating hospitals or institutions. This includes the names and addresses of those institutions, dates of affiliation, and the applicant's position during that time. The applicant must also authorize the release of their information to the Texas Medical Board and other relevant organizations.
If the evaluating physician identifies any concerns regarding the applicant's professional conduct, behavior, or training history, they are required to provide detailed explanations for any "yes" responses in the evaluation section. This includes any instances of disciplinary actions, limitations placed on the applicant, or other unusual circumstances. Such information is critical for the Texas Medical Board to assess the applicant's suitability for licensure.
Filling out the L For Texas Medical Board form can be a straightforward process, but several common mistakes can complicate the application. One significant error is neglecting to provide evaluations from every facility affiliated with the applicant in the past five years. The form explicitly states that evaluations are necessary from all relevant institutions, and failing to include any can lead to delays or complications in the licensure process.
Another frequent mistake involves inaccuracies in the applicant's personal information. Applicants sometimes misstate their current full name or date of birth. Even minor discrepancies can cause confusion and may require additional verification, further prolonging the application process. It is essential to double-check this information for accuracy before submission.
Many applicants also overlook the requirement to specify their position at the time of affiliation. Whether the applicant was an intern, resident, fellow, faculty, or staff member, this detail is crucial. Omitting this information can lead to misunderstandings about the applicant's qualifications and experience.
In addition, some applicants fail to complete the sections related to postgraduate training and professional history thoroughly. The form requires detailed information about training positions, including specific dates and any unusual circumstances. Incomplete sections can raise red flags for the reviewing board, potentially resulting in a request for additional information or clarification.
Misunderstanding the authorization section is another common pitfall. Applicants sometimes fail to sign the authorization, which is necessary for the Texas Medical Board to obtain relevant information. Without a signature, the application may be deemed incomplete, halting the review process.
Additionally, the method of submission can lead to issues. Evaluators must send the completed form directly to the Texas Medical Board via mail, fax, or email. Some applicants mistakenly submit the form themselves or use non-official email addresses, which the board does not accept. Ensuring that the evaluator follows the correct submission protocol is vital.
Lastly, applicants may not provide accurate contact information for the evaluating physician. The form requires the evaluator's name, title, and contact details. If this information is incorrect or missing, it could delay the verification process, as the board may struggle to reach the evaluator for necessary confirmations.
When applying for licensure with the Texas Medical Board, several forms and documents may be necessary to support the application process. Each of these documents serves a specific purpose and helps ensure a thorough evaluation of the applicant's qualifications. Below is a list of important forms often used alongside the L For Texas Medical Board form.
Completing these forms accurately and submitting them in a timely manner can significantly impact the licensure process. Each document plays a vital role in presenting a comprehensive view of the applicant's qualifications and professional history. Ensure that all forms are filled out completely and submitted as directed to facilitate a smooth evaluation process.
When filling out the L for Texas Medical Board form, it is essential to follow specific guidelines to ensure a smooth application process. Here are eight things you should and shouldn't do:
By adhering to these guidelines, you can help facilitate a more efficient review of your application.
This is incorrect. The Texas Medical Board form mandates evaluations from every facility the applicant has been affiliated with in the past five years. It's crucial to gather all necessary evaluations to avoid delays in the licensure process.
In reality, the Texas Medical Board specifically states that letters of recommendation or standard institution verification forms are not acceptable in lieu of the required evaluation form. Only the designated evaluation from an authorized physician will be accepted.
This is not true. The completed evaluation must be sent directly from the evaluating physician to the Texas Medical Board. Submissions from the applicant will not be accepted.
This misconception overlooks the confidentiality of the information. While the Texas Medical Board must provide a copy of the form to the applicant if their application is referred to the Licensure Committee, all information is confidential under the Medical Practice Act until that point.
This is misleading. While the form does specify that training positions require a verification of postgraduate training, non-training positions also necessitate a verification of professional history. Both sections are important for a complete evaluation.
This is incorrect. The evaluation must be completed by a physician holding a specific position, such as Chief of Staff, Department Chairman, Medical Director, or Training Director. This ensures that the evaluation is credible and authoritative.
Complete the applicant information accurately. This includes the applicant's full name, date of birth, and contact information. Incomplete details may delay the evaluation process.
Every facility affiliated with the applicant in the past five years must provide an evaluation. Be aware that the Texas Medical Board may request additional evaluations beyond this timeframe.
Evaluators must hold specific positions such as Chief of Staff, Department Chairman, Medical Director, or Training Director. Other forms of verification, like letters of recommendation, are not acceptable.
Submit the completed evaluation directly to the Texas Medical Board. This can be done via mail, fax, or email, but ensure that the correct procedures are followed for each method.
When sending by mail, seal the evaluation in an envelope and sign over the flap. This helps maintain confidentiality and ensures that the submission is recognized as official.
For fax submissions, include an official coversheet from the hospital or institution. Faxes sent without this cannot be accepted.
Understand that all information provided is confidential but may be shared with the applicant if their application is referred to the Licensure Committee. Transparency in the evaluation process is crucial for both the applicant and the board.