Provisional License Application and Sponsorship Form
This document is the Provisional License Application and Sponsorship Form for Texas physicians. It outlines the process for obtaining a limited provisional license to practice in Health Professional Shortage Areas or Medically Underserved Areas. Ensure that all required fields are completed accurately to facilitate your application.
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How do I fill this out?
To fill out this form, start by providing your personal information and practice address. Next, affirm your intention to practice in a designated HPSA or MUA area. Finally, ensure that a sponsoring physician's information is included and sign the document.
How to fill out the Provisional License Application and Sponsorship Form?
1
Provide your name and TMB Identification Number.
2
Fill out the Practice Address where you intend to work.
3
Confirm your intention to practice in a specified HPSA or MUA.
4
Include your sponsoring physician's information.
5
Sign and date the application form.
Who needs the Provisional License Application and Sponsorship Form?
1
Physicians seeking a provisional license to practice.
2
Medical residents applying for temporary practice.
3
Practitioners moving to Texas from other states.
4
Sponsors for physicians needing to provide oversight.
5
Healthcare providers in underserved areas needing approval.
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What are the instructions for submitting this form?
To submit this form, ensure all required fields are filled and verify the accuracy of the information provided. You can submit the completed form via email to TexasPCO@dshs.state.tx.us or by faxing it to the Texas Medical Board's submission department. Alternatively, mail it to the Texas Medical Board at PO Box 2018, Austin, TX 78768-2018. Always keep a copy for your records.
What are the important dates for this form in 2024 and 2025?
In 2024, it is essential to submit this form before the expiration of any existing provisional licenses. Keep in mind that provisional licenses can only be issued for a maximum of 270 days. For 2025, ensure you submit ahead of any regulatory updates that may affect your application.
What is the purpose of this form?
The purpose of the Provisional License Application is to allow physicians to practice medicine temporarily in designated areas experiencing shortages of healthcare professionals. It facilitates the provision of medical services in medically underserved regions, supporting public health initiatives. This form serves to document the intention to practice and the necessary sponsorship for provisional licensing.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The applicant's full name.
- 2. TMB Identification Number: The unique identifier assigned by the Texas Medical Board.
- 3. Practice Address: The location where the applicant intends to practice medicine.
- 4. Sponsoring Physician Name: The name of the physician sponsoring the application.
- 5. Sponsoring Physician License Number: The Texas License Number of the sponsoring physician.
- 6. Applicant's Signature: The signature of the applicant affirming their intent.
- 7. Date: The date when the application form is signed.
What happens if I fail to submit this form?
Failure to submit this form may result in the inability to legally practice medicine in Texas. It is crucial to complete and submit the application within the allowed timeframe to avoid interruption of services.
- Legal Practicing Status: You may be unable to practice medicine until the application is completed.
- Compliance Issues: Non-compliance with the state regulations could lead to penalties.
- Loss of Sponsorship: If the application is not submitted in time, you may lose your sponsoring physician.
How do I know when to use this form?
- 1. Temporary Licensure: For physicians looking to establish temporary practice.
- 2. Sponsorship Requirement: To comply with the Texas Medical Board's sponsorship requirements.
- 3. Service in Underserved Areas: To provide critical health services in regions needing medical professionals.
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