New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 1 of 14
New Mexico Medical Board
2055 S. Pacheco Street, Building 400
Santa Fe, NM 87505
505-476-7220
Fax: 505-476-7233
Michelle Lujan Grisham Peter T. Beaudette, MD
Governor Chair
TO ALL APPLICANTS
Thank you for requesting an application for a license to practice medicine in New Mexico. We look forward to
working with you to process your application.
A license to practice medicine in New Mexico is a privilege, not a right. The statutory mandate of the New
Mexico Medical Board is to protect the health and safety of the citizens of the state, and the members of the
Medical Board take their responsibilities very seriously. Upon completion, your application will be reviewed
for quality assurance and reviewed by the medical and executive directors of the Board. You may be required to
come to the Board Office in Santa Fe for an interview as part of the application process. Please do not assume
that licensure is a mere formality or that the granting of a license is automatic.
PLEASE DO NOT: close your practice and move your family to New Mexico, enroll your children in school,
begin construction of a new home, execute contracts with prospective practice partners, schedule patients, or
begin practicing until you have received a license.
We will make every effort to complete the application process as quickly as possible but occasionally we
encounter unanticipated questions or difficulties that may cause delay or even denial. We will not begin
working on your application until we have received a completed NM Statewide application and all required
fees. Please understand that much of the supporting documentation for your application has to be obtained from
third parties, which can add time to the licensing process. In addition, some applications, such as those with a
history of disciplinary action, require in-depth investigation that may take extra time and require your
cooperation.
One sure way to make certain that your application is processed as efficiently as possible is to read the
directions carefully and call or email the Board office if you have any questions. Our staff will be happy to
assist you in any way we can.
Again, thank you for your application. We look forward to working with you to make this process as rapid and
painless as possible!
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 2 of 14
BASIC REQUIREMENTS FOR ALL APPLICANTS
I. EXAMINATION REQUIREMENTS
Applicants for licensure by examination must have attained a passing score of at least 75 on each required exam. An
applicant may attempt to successfully complete any part of a board-approved examination six times, as long as the entire
examination is successfully completed within seven years from the date the first step of the examination is passed.
MD/PhD candidates must successfully complete the entire examination within ten years from the date the first step of the
examination is passed.
• Board Approved Examinations (for more specific information see Part 3 of rules):
1. All three “steps” of the United States Medical Licensing Examination (USMLE).
2. Two “components” of the Federation Licensing Examination (FLEX).
3. All three “parts” of the National Board of Medical Examiners examination (NBME). (MD Only)
4. All three “parts” of the National Board of Examiners of Osteopathic Medical examination (NBOE). (DO Only)
5. Three “components” of the Comprehensive Osteopathic Medical Licensing Examination (COMPLEX). (DO
Only)
6. Any of the above listed in (1), (2) or (3) in an approved “hybrid” combination, per Board rule 16.10.3.8 NMAC.
7. The Board will accept the results of State Board examinations if taken and passed before December 1973 (one of
the national licensing examinations is required after that date).
8. Medical Council of Canada Qualifying Examination (MCCQE).
9. International medical graduates must have passed the ECFMG exam plus one of the approved combinations listed
in Board rule 16.10.3.8 NMAC.
II. REQUIREMENTS FOR LICENSURE BY EXAMINATION
• Education Requirements: All applicants must have graduated and received a diploma from a New Mexico Board
approved school, or present proof of completion of a program substantially equivalent to an United States medical
school as determined by an international education credential evaluation service approved by the Board.
• Postgraduate Training Requirements: All applicants for a license must have satisfactorily completed twenty-four
(24) months of postgraduate medical education in a program approved by the Board. The ACGME Graduate Medical
Education Directory and the Directory of Residency Programs of the Royal College of Physicians and Surgeons of
Canada are the official lists approved by the Board.
• Examination Requirements: All applicants for licensure by examination must have successfully passed one of the
examinations or combination of examinations listed above.
III. REQUIREMENTS FOR LICENSURE BY ENDORSEMENT
Applicants who meet ALL of the following requirements may apply for licensure by endorsement, which means the Board
does not require primary source verification of medical education, transcripts, postgraduate training and examination
history:
1. Hold an unrestricted license in another state and be free of disciplinary history, license restrictions, or pending
investigations in all states where they hold a license;
2. Graduated from an approved medical school or hold current ECFMG certification;
3. Hold current certification from a medical specialty board recognized by ABMS or AOA-BOS; and
4. Has been a licensed physician in the United States or Canada and has practiced medicine (not including
postgraduate training) in the United States or Canada immediately preceding the application
for at least three years.
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 3 of 14
A complete copy of the rules may be downloaded from the website at www.nmmb.state.nm.us. Part 2 of the rules addresses licensure
requirements in detail, and Part 3 addresses examinations approved by the Board.
B. COMPLETING THE APPLICATION FORM
You may choose from completing an online application or paper application form to obtain licensure in New
Mexico. Step-by-step instructions are included in this instruction material. All methods begin with the
Statewide Application for licensing, approved by the NM Medical Society and the NM Hospital Association.
Apply directly to the NM Medical Board-Paper Application or Online Application
This application process requires you to request required documentation verifying your professional
recommendations, licenses, work history and hospital and healthcare affiliations, medical education, post-
graduate training, and examination history from the source and have it sent directly to the Board office from
the source.
C. OPTIONS FOR USING CREDENTIALING ORGANZATIONS FOR GATHERING
SOURCE DOCUMENTS
New Mexico Hospital Services Corporation Credentials Verification Organization (HSC)
HSC will obtain nearly all the required documents for your license application and will also have the
information available to process your application for privileges at most New Mexico hospitals and
credentialing for all health plans in the state. HSC is “one stop” credentialing to help you start practice as soon
as possible. HSC is able to process applications by examination and endorsement. HSC will obtain affiliation
and employment verification, license and board certification verification, peer references, and verify education
if applicable.
HSC is NCQA accredited and is endorsed by the New Mexico Medical Society. Please contact HSC at 505-
346-0222 or toll free 866-908-0070 ext. 2006 to arrange utilizing their services. For more information, please
contact [email protected] or visiting their website at
https://ecredspractitioner.nmhsc.com/Account/Login?ReturnUrl=%2F
Federation Credentials Verification Service (FCVS)
(Not to be used if qualifying by endorsement)
If you think that you may apply for licenses in several states over the coming years, completion of using the
Federation of State Medical Boards (FSMB) Federation Credentials Verification Service (FCVS) to supply core
documents (verification of medical education, PGT and exam history) may save you time and money by
requiring only one set of source documents for your education and training. You must still complete the
Statewide MD Application and submit it to the NMMB with the applicable fee. FCVS requires a one-time
submission of education and training documents directly to a depository maintained by FSMB. Once an
applicant satisfies FCVS criteria, those documents that do not change over time need not be reproduced when
you apply for a license in another jurisdiction (e.g., transcripts, postgraduate training records, exam
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 4 of 14
scores). Again, the idea is to expedite the application process and eliminate the duplication of education and
training documents each time you seek licensure in another state. Not all jurisdictions accept FCVS documents,
but most states do and some actually require its use. You may obtain additional information or an application to
apply for a FCVS Profile by calling 1-888-ASKFCVS (275-3287) or checking their website at www.fsmb.org,
then the link to the Credential Verification Service.
We strongly encourage you to retain a copy of your application prior to submitting into the Board
Office.
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 5 of 14
C. CRIMINAL HISTORY BACKGROUND CHECK
Like other state medical boards around the country, the NM Medical Board will conduct criminal background checks in
order to fulfill its statutory mandate to protect the health and safety of the NM public. The applicant is responsible for any
costs associated with obtaining fingerprints.
Will the criminal background check slow down my license application?
An application for initial licensure will not be considered complete until the required fingerprinting has been completed.
However, completed applications will be processed pending the outcome of the background check, and licenses may be
granted while the screening is still pending. If the background check reveals a felony or a violation of the Medical
Practice Act the licensee will be notified and the Board will determine if the applicant is eligible for licensure or if
disciplinary action will be taken against the licensee.
The State of NM has recently partnered with Gemalto to improve the public availability of fingerprint services,
shorten background check response times and increase applicant convenience.
PLEASE DO NOT SEND YOUR FINGERPRINTS TO THE BOARD. WE WILL NOT ACCEPT THEM AND
THEY WILL BE RETURNED TO YOU.
PLEASE READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY
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New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 6 of 14
If you are a current resident of NM, please follow
the instructions below:
ALL APPLICANTS MUST REGISTER ONLINE
1. To register, please visit
https://www.aps.gemalto.com/index.htm
and click on the State of NM logo.
While online registration is the
preferred registration method, telephone
registration can also be completed by
calling 1-877-99NMAPS (1-877-996-
6277)
2. Go to the “Applicant Use” Section of
the webpage
3. Click on the Register Online for a
Background Check link. (Registration is
the process of collecting demographic
information (name, height, eye color,
etc) and collection of payment. The
new fee for fingerprint service is
$45.25.
4. Once Registration and payment are
complete the applicant will receive a
registration ID (REG ID) that is unique
to their fingerprinting record.
5. Visit one of the NMAPS fingerprint
sites. Please see attached list of
approved sites in NM or go to
https://www.aps.gemalto.com/index.htm
> New Mexico > Print Locations and
Hours.
6. The REG ID and a valid form of
identification are required at the
fingerprint site. You must be registered
prior to arriving at a fingerprint site.
7. The following are required at the
fingerprint site: Valid Photo ID (such
as Driver’s License or State ID card),
Registration ID and Money Order (If
this was your selected payment method)
Questions? Please visit the Useful Links portion of the website and see FAQ’s
**You will have 90 days from the time of registration to get your fingerprints completed. After
90 days, your registration will be cancelled, and you will need to begin the process once again.
**
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 7 of 14
Applying to the NM Medical Board (Paper Application Form)
Step 1: Complete the NM Statewide application in its entirety. Please type or print legibly in blue or black ink.
An incomplete application will delay processing.
Step 2: The following documentation and fees must be included with the Statewide MD Application:
a. Application fee of $400 made payable to the New Mexico Medical. Applications will not be processed
until the application fee has been received. The application fee is payable in U.S. funds by cashier’s
check, money order, personal check, MasterCard or Visa. All fees are non-refundable.
b. A copy of your specialty board certificate and re-certification, if applicable.
c. Completed “Applicant’s Oath” including a passport-quality color photo of the applicant taken within
the last six months.
d. International medical graduates must submit a copy of their ECFMG certificate or fifth pathway
certificate in addition to the information required above.
Step 3: Attach your payment to the Board to the front of the application. Your payment to the Board must be in
U.S. funds, and may be in the form of personal check, money order, Visa, or MasterCard. If you are using a
Visa or MasterCard, please provide the type of credit card, number and expiration date on a cover letter. Do not
send cash. Mail your completed application to:
New Mexico Medical Board
2055 S. Pacheco St. Bldg. 400
Santa Fe, NM 87505
Step 4: The following documentation must be requested by the applicant and submitted directly from the source
to the Board. THE BOARD WILL NOT ACCEPT THESE DOCUMENTS FROM THE APPLICANT.
If you qualify for licensure by endorsement, you are not required to have your examination history
verified for the NM Medical Board.
a. Verification of Examination Scores. The NMMB requires verification of exam scores directly from the
source.
• National Board scores may be obtained by calling 215-590-9592 or downloading the required
request form at www.nbme.org.
• USMLE, Flex and SPEX scores may be obtained from the Federation of State Medical Boards by
calling 817-868-4000, or by visiting www.fsmb.org.
• NBOME/COMLEX-USA scores may be obtained by requesting a certified copy by going to
www.nbome.org/assessments/ (see link on the NBOME transcript page) You can also call 866-
479-6828.
• MCCQE scores can be requested by calling 613-521-6012.
• State board exam scores and pass date should be requested with the Verification of Licensure
form.
b. If you are an international medical graduate (IMG):
• Please contact ECFMG at 215-386-5900 or www.ecfmg.org to request a Status Report of
ECFMG Certification be sent directly to the New Mexico Medical Board, or
• Request certification of successful completion of the fifth pathway program, if applicable,
directly from the school.
• Both examination scores (USMLE, Flex, National Board) AND ECFMG Certification are
required to be sent to the Board.
• Note: Documents in languages other than English must be translated and the translation
certified as accurate. Documents without a certified translation will not be accepted.
New Mexico Medical Board Uniform Application Instructions
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Step 5: The following documentation must be requested by the applicant and submitted directly from the
appropriate source directly to the NM Medical Board. If you qualify for licensure by endorsement, you
are not required to have your medical education, transcripts, postgraduate training and examination
history verified for the NM Medical Board (see Eligibility for Licensure in New Mexico for details), but
are required to have completed Verification of Work Experience forms from all work history and
hospital and healthcare affiliations for the past 5 years, two completed Professional Recommendation
Forms, and verification of each and every license regardless of the status sent directly to the NM
Medical Board.
a. Certification of Medical Education and Certified Transcripts. You are required to have the Medical
Education completed in its entirety (pages 1 and 2) by your medical school and returned directly to the
NM Medical Board along with a certified copy of your transcripts posting you degree and degree date.
b. Certification of Postgraduate Training. You are required to have the Postgraduate Training
Verification form completed in its entirety by all PGT programs enrolled in and return the completed
form(s) directly to the NM Medical Board.
c. Verification of Work Experience. You must have the chief of staff or administrator in each and every
hospital or health facility where you have held privileges or been employed during the past two (2) years
(not including internship, residency, or fellowship) complete the Work Experience Verification form(s)
and return the completed form(s) directly to the NM Medical Board.
d. Professional Recommendations. In addition to the documents identified above and in place of “letters
of recommendation,” the NMBME requires two Professional Recommendation forms sent directly to the
Board from physicians, chiefs of staff, department chairs or equivalent with whom the applicant has
worked and who have personal knowledge of the applicant’s character and competence to practice
medicine. The recommending physicians must have personally known the applicant and have had the
opportunity to personally observe the applicant’s ability and performance. The completed Professional
Recommendation forms must be sent directly to the NM Medical Board from the recommending
physician.
e. Verification of Licensure. You must have each state or territorial licensing authority which has ever
issued you a license to practice medicine (including temporary licenses and education/training permits,
regardless of the status) send verification of that license directly to the NM Medical Board.
Step 6: Personal Interview. The NM Medical Board no longer requires every applicant be scheduled for a personal
interview. If you are required to schedule an appointment for a personal interview with the Board or the
Board’s designee, you will be notified after your application and all required documents have been received
and are complete in every detail.
Step 7: License. Applicants whose applications are approved for licensure will be issued a license to practice in
New Mexico. Medical licenses shall be renewed on July 1 following the date of issue. Initial licenses are
valid for a period of not more than 13 months or less than 1 month.
New Mexico Medical Board Uniform Application Instructions
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INSTRUCTIONS FOR COMPLETING THE LICENSE APPLICATION FOR
TELEMEDICINE LICENSE
Definition: The practice of medicine across state lines as defined in the Medical Practice act, Sections 61-6-6, K NMSA
1978. A telemedicine license is a limited license that allows a physician located outside New Mexico to practice medicine
on patients located in New Mexico.
Requirements: Each applicant for a Telemedicine license must be of good moral character and hold a full and
unrestricted license to practice medicine in another state or territory of the United States.
Instructions:
Step 1: Complete the NM Statewide Application in its entirety. Please type or print legibly in blue or black ink. An
incomplete application will delay processing.
Step 2: The following documentation and fee must be included with the application:
a. Application fee of $400 made payable to the New Mexico Medical Board.
b. Completed form entitled “Applicant’s Oath” including attaching a passport-quality color photo of the
applicant taken within the last six months.
c. Copy of your Specialty Board Certificate and re-certification, if applicable.
Step 3: Attach your payment to the Board to the front of the application. Applications will not be processed until
the application fee has been received. The application fee is payable in U.S. funds by cashier’s check, money
order, personal check, Visa, or MasterCard. All fees are non-refundable. Mail your application and fee to:
New Mexico Medical Board
2055 S. Pacheco St. Bldg. 400
Santa Fe, NM 87505
Step 4: The following documentation must be requested by the applicant and submitted directly from the source to
the Board. WE WILL NOT ACCEPT THESE DOCUMENTS FROM THE APPLICANT.
a. Verification of Licensure: You must have each and every state or territorial licensing authority which ever
issued you a license to practice medicine (including temporary licenses and education/training
permit, whether active or inactive) verify the standing of that license to the Board. You need to
contact each licensing authority to inquire if they charge a fee to verify the license and send them
the fee, if applicable, with the request form.
Licensure Process: Upon receipt of a completed application, including all required documentation and fee, Board staff
will request and review an AMA or AOA Physician Profile and Federation of State Medical Boards Board Action
Databank Search. When the application is complete in every detail, it will be reviewed for quality assurance and then
forwarded to the Board designee for review and possible approval for licensure. A personal interview is not required
unless there is a discrepancy in the application that cannot be resolved.
Initial License Expiration: Telemedicine licenses expire on July 1 following the date of issue. Initial licenses are valid
for a period of not more than thirteen months or less than one month.
New Mexico Medical Board Uniform Application Instructions
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LICENSURE APPLICATION PROCESS
Step 1: Determine which of the following three methods you will use to apply to the NM Medical Board.
1. Applying Directly: You request all required documentation verifying your professional recommendations, licenses,
work history and hospital and healthcare affiliations, medical education, post-graduate training, and examination
history from the sources and have each source send the materials directly to the Board office. If you choose this
method, you will need to follow essentially the same process next time you apply for a license in another state. In
addition, when you begin practicing in New Mexico you may still need to go through HSC for credentialing
purposes.
2. Using HSC: If you are getting ready to start practice in New Mexico, we suggest you apply through the NM
Hospital Services Corporation Credentials Verification Organization (HSC). They will not only provide nearly all
of the required documents for your license application, but they will also have the information available to process
your application for privileges at most New Mexico hospitals and credentialing for all health plans in the state. It’s
“one stop” credentialing to help you start practice as soon as possible and is endorsed by the New Mexico Medical
Society.
3. Using FCVS: If you think that you may apply for licenses in several states over the coming years, consider using
the Federation of State Medical Boards (FSMB) Federation Credentials Verification Service (FCVS). FCVS verifies
primary source documents related to your identity, medical education, postgraduate training, and more, and then
creates an individualized profile that can be sent to any organization accepting FCVS. By eliminating the re-
verification of items that never change, physicians benefit from a shortened credentialing process when applying to
more than one state board. 97% of state boards accept or require FCVS.
To work on the initial FCVS application for creating a profile or the subsequent FCVS application for updating an
existing profile, visit https://www.fsmb.org/fcvs/ and select FCVS in the Licensure or Sign In menu, then sign in as
directed. Please note that FCVS is for credentials verification only. The Uniform Application (UA) is the licensure
application.
For assistance, use the messaging tool within FCVS or call 888-275-3287 with your FCVS ID number between 8am
and 5pm CT on weekdays.
Regardless of what application method you use, we urge you to retain a copy of your application.
Step 2: Complete the Uniform Application for Physician State Licensure (UA).
The Uniform Application makes the licensure application process easier by eliminating redundancy. After completing the
UA online for the first time, your application is securely stored and can be resubmitted to another state board using the UA
without reentering the same information. You would only make updates as needed and ensure that you comply with any
board-specific requirements.
In the UA, you will be asked to account for all time since medical school graduation, including providing your employment
history, and asked to provide any information on medical malpractice claims. We recommend having this information on
hand before you begin working on your UA.
To work on the UA, go to https://www.fsmb.org/uniform-application/ and select Uniform Application from the Licensure
menu or Sign In menu. If you have submitted a UA previously, select the state board in the State Board section to open the
UA for editing. Submit your UA to the board when you have finished updating your UA.
First time UA users are required to pay a one-time service charge of $60. Your receipt will be available immediately after
submitting your UA, and you will receive a separate receipt via email.
New Mexico Medical Board Uniform Application Instructions
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The UA FAQ at https://www.fsmb.org/uniform-application/ua-faq/ answers the most common UA questions. If your
question or issue isn’t listed, contact UA customer service at 800-793-7939 or email [email protected] with your username or
FCVS ID if applicable, and a description of what you were doing at the time.
Please note the following:
• Provide both your current home address and current business practice/training address, otherwise an error will
occur. Do not enter the same address for both home and work. You can use the same address for both Board Contact
and Public Contact.
• You are not able to add or edit MD and DO licenses in the UA as that information comes directly into the system
from the state boards. Email ua@fsmb.org with the correct information if changes are needed.
• Enter all other professional licenses (nurse, EMT, physician assistant, etc.) you have held (active or inactive) in the
U.S. or Canada. Request verification from these boards as well.
• If you hold licenses in countries outside the U.S. or Canada, please provide that information on a separate sheet of
paper to the Board.
• On the Chronology of Activities, if “Military Service” is reported, please provide a copy of your discharge or
separation documents.
• For all locations where you have had admitting privileges, check the “Staff Privileges” box.
• Providers who do NOT have admitting privileges, please explain on a separate sheet of paper your procedures or
the arrangements you make in instances when patients require admission to a hospital. If you are applying with a
health plan, should arrangements include admitting coverage by another provider, a signed letter from the covering
provider, including their primary admitting facility, is to be included.
• Clinical time indicates time spent with patients. Administrative indicates time spent on paperwork.
• For all malpractice claims, list as much detail as possible in the “specifics” section, including the name, age, sex of
patient/claimant, the nature of the allegations in claims/suits (specify whether a suit was ever filed), names of other
practitioners and hospital (if any) involved in claims/suits, name of defense attorney.
In addition to completing the core UA online, all applicants must:
• Submit a UA Affidavit and Authorization for Release of Information form to the Board. The UA Affidavit is
separate from the FCVS Affidavit and must be sent directly to the Board. Attach a recent (less than 6 months old)
two inch by two-inch (2” x 2”) passport quality, color photograph of yourself (head and shoulders only) in the space
provided. Proof photos, negatives, and digital photos are not acceptable. This form must be notarized and returned
to the New Mexico Medical Board.
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• Have each full, temporary, training, or limited healthcare or profession license or certification you have
ever held in the U.S. or Canada verified by the granting board, whether the license or certification is active
or inactive. Determine the fees and verification method for each board using the licensure verification
resource at https://www.fsmb.org/uniform-application/. Use the UA Licensure Verification Form for
boards that need a written request. If the verifying board uses VeriDoc or another method, use that
method instead.
• Complete the three addenda as instructed.
o Addendum 1 – Additional Physician Information form. Provide all information requested. If you
answer YES to any of the Professional Practice Questions, please give details including name,
address, and telephone number of significant parties on a separate sheet of paper.
o Addendum 2 – Professional Recommendation form. Complete the top portion of two copies of
this form. The NMBME requires two Professional Recommendation forms sent directly to the
Board from physicians, chiefs of staff, department chairs or equivalent with whom you have
worked and who have personal knowledge of your character and competence to practice
medicine. The recommending physicians must have personally known you and have had the
opportunity to personally observe your ability and performance. The completed forms must be
sent directly to the New Mexico Medical Board from the recommending physicians.
o Addendum 3 – Work Experience Verification form. Complete the top portion of the form, including
dates. You must have the chief of staff, administrator, or medical staff services of each and every
hospital and/or health facility where you have been granted and/or held privileges and/or been
employed during the past two (2) years if applying by examination, and past three (3) years if
applying by endorsement (not including internship, residency, or fellowship), complete the rest of
the form in its entirely and send it directly to the New Mexico Medical Board.
If you are using FCVS for credentials verification,
• Do not complete the UA Medical Education, Postgraduate Training, or Fifth Pathway Verification forms,
or send identity documents, transcripts, certificates, or examination scores to the Board. FCVS handles
all of this for you.
If you are not using FCVS for credentials verification,
• Send to the Board a certified copy of a legal name change document (marriage certificate, divorce decree,
court order) if your name is not the same on all of your submitted documents.
• Contact each appropriate exam entity to have a certified transcript of your scores sent directly to the
Board. If you have taken any component of the NBME in conjunction with another exam (USMLE/FLEX),
request your transcript from the NBME. For contact information, see the UA FAQ at
https://www.fsmb.org/uniform-application/ua-faq/.
• Complete the UA Medical Education Verification, Postgraduate Training Verification, and Fifth Pathway
Verification (if applicable) forms as directed on each form. The UA Medical School Verification form
should be accompanied by a copy of your diploma if you graduated from that school.
• If you are an International Medical Graduate, request from ECFMG that your ECFMG certificate, Fifth
Pathway Program Certificate, and/or FMGEMS certificate be sent to the Board, as applicable. See the
UA FAQ at the link on the previous page for contact information.
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Step 3: Prepare your documents and fees and mail to the appropriate locations.
The checklist on the last page of these instructions should be used to ensure that you complete all requirements
and send all paperwork to the correct locations. Depending on your method of application and what is applicable
to your situation, you must send the following items directly to the New Mexico Medical Board:
1. Application fee of $400 made payable to the New Mexico Medical Board (or $50 if you are enrolled in
a postgraduate training program in New Mexico and are applying for a Public Service License. Please
have your Program Director send the NMMB a letter granting you permission for a Public Service
License). Applications will not be processed until the completed Uniform Application Addenda and
application fee have been received. The application fee is payable in U.S. funds by cashier’s check,
money order, personal check, MasterCard or Visa.
2. When you provide a check as payment, you authorize the State of New Mexico to either use
information from your check to make a one-time electronic fund transfer from your account or to
process the payment as a check transaction. All fees are non-refundable.
3. If using HSC, include a check in the amount of $320 made payable to NMHSC. A copy of the application
and your check will be forwarded to HSC from the Board. HSC will bill the applicant for any add-on costs
required to obtain the source documents. These may include license verifications or notarized proof of
education.
4. If you are an international medical graduate, include a copy of your ECFMG certificate or Fifth Pathway
certificate.
5. If you are not a US citizen, you must provide proof of compliance with immigration laws (copies of
naturalization papers, passport, J-1 or H-1 visa).
6. A notarized copy of your birth certificate or a current, valid passport.
7. Supporting documentation of any legal name change.
8. A copy or copies of your examination transcript(s).
9. A copy of your specialty board certificate and re-certification, if applicable.
10. Applicable forms and addenda within the Uniform Application. The Affidavit and Authorization for Release
of Information form and the Additional Physician Information form are required for all application methods.
11. Other required documentation as needed (military discharge/separation documents, written
arrangements for admitting if lacking privileges, letter from treating physician, details to professional
practice questions with “yes” answers, etc.).
Attach your payment to the Board to the front of your application documents. Your payment to the Board
must be in U.S. funds and may be in the form of personal check, money order, Visa, or MasterCard. If you are
using a Visa or MasterCard, please provide the type of credit card, number, and expiration date on a cover letter.
Do not send cash. Mail your documents to: New Mexico Medical Board, 2055 S. Pacheco St. Bldg. 400, Santa
Fe, NM 87505.
Step 4: Complete a criminal history background check.
Beginning in July 2007, the New Mexico Medical Board began requiring that all applicants for initial licensure
submit fingerprints and other information for a state and national background check at their cost. Like other state
medical boards around the country, the New Mexico Medical Board conducts criminal background checks in
order to fulfill its statutory mandate to protect the health and safety of the New Mexico public. A background
New Mexico Medical Board Uniform Application Instructions
Revised: September 2021 Page 14 of 14
check packet, including blank fingerprint cards and instructions, will be sent to you upon receipt of your
Uniform Application Addenda and application fee. Fingerprint cards cannot be downloaded from the Board’s
web site.
The criminal background check may or may not slow down your license application. A license will not be issued
until the Board has confirmation of your background check. If the background check reveals a felony or a violation
of the Medical Practice Act, you will be notified, and the Board will determine if you are eligible for licensure or if
disciplinary action will be taken against you.
You must have your fingerprints taken by a qualified individual. Qualified individuals include, but are not limited
to, a public law enforcement official. Public Law enforcement agencies include county sheriff, state, municipal,
campus, military, and tribal police. In some locations it may be possible to find other agencies with staff trained
to take fingerprints, including hospitals, medical centers, and local school districts. Some agencies may charge
a fee to take fingerprints. You are responsible for any costs associated with obtaining fingerprints.
Step 5 (if needed): Personal Interview.
The New Mexico Medical Board no longer requires every applicant be scheduled for a personal interview. If you
are required to schedule an appointment for a personal interview with the Board or the Board’s designee, you
will be notified after your application and all required documents have been received and are complete in every
detail.
APPROVAL OF LICENSURE
Applicants whose applications are approved for licensure will be issued a license to practice in New Mexico.
Medical licenses shall be renewed on July 1 following the date of issue. Initial licenses are valid for a period
of not more than 13 months or less than 1 month.
Please use the checklist on the next page to ensure you have completed each part of the licensure process.
New Mexico Medical Board Uniform Application Checklist
Revised: September 2021 Page 1 of 1
Uniform Application for Physician State Licensure Checklists
Please use the checklist that applies to you. Items beginning with a * should be sent directly to the NMMB.
Applying
Directly
Using
HSC
Using
FCVS
Completed online Uniform Application.
*Sent the Affidavit and Authorization for Release of Information form (within the
online UA) to the NMMB.
*Sent Addendum 1 (Additional Physician Information form) to the NMMB.
Sent Addendum 2 (Professional Recommendation form) as instructed.
Completed
via HSC
Sent Addendum 3 (Work Experience Verification form) as instructed.
Completed
via HSC
*Sent application fee of $400 made payable to New Mexico Medical Board to the
NMMB (unless enrolled in a postgraduate training program and applying for a
Public Service License, in which case a letter from your Program Director
granting you permission for a Public Service License must be sent with a $50
application fee).
*Sent a copy of your specialty board certificate and re-certification to the NMMB
(if applicable).
*Sent proof of compliance with immigration laws, e.g., copies of naturalization
papers, passport, J-1 or H-1 visa to the NMMB (if applicable).
*Sent notarized copy of birth certificate or current, valid passport to the NMMB.
Completed
via HSC
Completed
via FCVS
*Sent supporting documentation of any legal name change to the NMMB.
Completed
via HSC
Completed
via FCVS
Sent Licensure Verification Form (Form #1 within the online UA) to each state
board with which you have ever held any health care license or used VeriDoc or
the board’s preferred method of verification.
Completed
via HSC
Sent Medical School Verification form (Form #2 within the online UA) and a copy
of your diploma to each medical school attended.
Completed
via HSC
Completed
via FCVS
Sent Postgraduate Training Verification form (Form #3 within the online UA) to
all training programs attended.
Completed
via HSC
Completed
via FCVS
*Sent a copy of your postgraduate training certificate(s) to the NMMB.
Completed
via HSC
Completed
via FCVS
*Sent all examination transcripts to the NMMB.
Completed
via FCVS
Sent Fifth Pathway Verification form (Form #4) to the program director at the
medical school/institution (if applicable).
Completed
via FCVS
*Sent a copy of your ECFMG certificate (if applicable) to the NMMB.
Completed
via FCVS
*Sent all additional required documentation (military discharge/separation
documents, written arrangements for admitting if lacking privileges, letter from
treating physician, details to professional practice questions with “yes” answers,
etc.) to the NMMB.
New Mexico Medical Board Uniform Application Instructions and Addendum 1
Revised: September 2021 Page 1 of 5
New Mexico Medical Board
2055 S. Pacheco Street, Building 400
Santa Fe, NM 87505
505-476-7220
Fax: 505-476-7233
Michelle Lujan Grisham Peter T. Beaudette, MD
Governor Chair
ADDENDA INSTRUCTIONS
Addendum 1 – Additional Physician Information form. Provide all information requested. If you answer YES to
any of the Professional Practice Questions except for Question 20, please give details including name, address,
and telephone number of significant parties on a separate sheet of paper.
Addendum 2 – Professional Recommendation form. Complete the top portion of two copies of this form. The
NMMB requires two Professional Recommendation forms sent directly to the Board from physicians, chiefs of
staff, department chairs or equivalent with whom you have worked and who have personal knowledge of your
character and competence to practice medicine. The recommending physicians must have personally known you
and have had the opportunity to personally observe your ability and performance. The completed forms must be
sent directly to the New Mexico Medical Board from the recommending physicians.
Addendum 3 – Work Experience Verification form. Complete the top portion of the form, including dates. You
must have the chief of staff, administrator, or medical staff services of each and every hospital and/or health
facility where you have been granted and/or held privileges and/or been employed during the past two (2) years
if applying by examination, and past three (3) years if applying by endorsement (not including internship,
residency, or fellowship), complete the rest of the form in its entirely and send it directly to the New Mexico
Medical Board.
New Mexico Medical Board Uniform Application Instructions and Addendum 1
Revised: September 2021 Page 2 of 5
N
ew Mexico Medical Board
2055 S. Pacheco Street, Building 400
Santa Fe, NM 87505
505-476-7220
Fax: 505-476-7233
Michelle Lujan Grisham
Peter T. Beaudette, MD
Governor Chair
ADDITIONAL PHYSICIAN INFORMATION
Please Indicate Type of Physician: MD DO
Physician Name: __________________________________ ______________________ __________________________
Last First Middle
An asterisk (*) indicates that this information will be kept confidential.
Will you be applying by endorsement? Yes No
Citizenship:
Immigration Status:
INS Certification #: N/A
*Fed Tax ID#: Pending N/A
*NM Tax ID#: Pending N/A
*Fed. Drug Enforcement Admin. (DEA) Registration #: Exp. Date: Pending N/A
*State Controlled Substance Registration (CSR)# State: Exp. Date: Pending N/A
*Medicare Unique Physician Identification Number (UPIN): Pending N/A
*State Medicaid Provider Number: State: Pending N/A
PRACTICE INFORMATION – Please list all applicable practice information below.
Current Practice Name:
Street Address:
City: State: Zip Code:
Telephone Number:
Facsimile Number:
*Office Manager or Contact Person:
Practice Limited to (clinical specialty):
Foreign Languages (spoken fluently by practitioner):
Foreign Languages (spoken fluently at Practice):
What are your immediate or future Practice Plans in New Mexico?
Practice Associates in NM (if applicable):
Call Coverage in NM (if applicable):
Other Practice Locations (if applicable):
Other Practice Name:
Street Address:
City: State: Zip Code:
Telephone Number:
Facsimile Number:
Answering Service:
Effective Date:
New Mexico Medical Board Uniform Application Instructions and Addendum 1
Revised: September 2021 Page 3 of 5
PROFESSIONAL REFERENCES – Please list three professional peers familiar with your professional performance in the
past 5 years (not including current or impending partners or associates in practice).
(1) Name and Title:
Street Address:
City: State: Zip Code:
Telephone Number:
Facsimile Number:
(2) Name and Title:
Street Address:
City: State: Zip Code:
Telephone Number:
Facsimile Number:
(3) Name and Title:
Street Address:
City: State: Zip Code:
Telephone Number:
Facsimile Number:
SPECIALTY BOARD CERTIFICATIONS N/A Are you Board Certified? Yes No
Note: If you are not Board certified by a Board recognized by the American Board of Medical Specialties, the American
Osteopathic Association, the National Commission on Certification of Physician Assistants, the American Nurses’
Credentialing Center, or the National Certification Commission, or accepted for examination in your specialty, please give
a brief explanation on an attached sheet.
Certified/Recertified by the:
Date Certified: Date Last Recertified: Exp. Date:
Certified/Recertified by the:
Date Certified: Date Last Recertified: Exp. Date:
Accepted for Examination by the:
Until (expiration date): If not accepted, have you made application? Yes No
Certified/Recertified by the Subspecialty Board of:
Date Certified: Date Last Recertified: Exp. Date:
Certified/Recertified by the Subspecialty Board of:
Date Certified: Date Last Recertified: Exp. Date:
Accepted for Examination by the Subspecialty Board of:
Until (expiration date): If not accepted, have you made application? Yes No
PROFESSIONAL LIABILITY INSURANCE*
Do you have current liability insurance? Yes No Pending
Current Carrier:
Complete address:
Dates Insured
From: To:
Policy #:
Coverage Limits:
New Mexico Medical Board Uniform Application Addendum 1
Revised: September 2021 Page 4 of 5
Professional Practice Questions (PPQs)
Read carefully before answering questions.
A. You must answer all questions. You must provide explanatory information –
▪ for any “yes” answer to questions numbered 1-18 and
▪ for any “no” answer to questions numbered 19-23.
Your failure to provide full and accurate details for any or all of those answers may result in disciplinary action
or denial of your application. If in doubt, disclose.
B. The Board expects full and accurate disclosure of all information. You must update any information that
changes while your application is pending.
C. The term “you” means you personally and any healthcare entity for which you serve as a business owner,
officer or medical director.
Licensing & Professional Membership
1. a. Regardless of the outcome, have you been subject to investigation by a licensing board or
other government entity that resulted or could have resulted in any type of sanction (e.g., fine,
reprimand, suspension, revocation, limitation, probation)?
b. Is any license you now hold under investigation or being challenged?
Yes
Yes
No
No
2. Have you ever been denied membership or renewal, or been subject to investigation or
discipline, by a professional organization?
Yes
No
3. Has a federal or state-controlled substance registration issued to you ever been voluntarily
or involuntarily restricted, limited, suspended, or revoked?
Yes
No
Education
4. Have you, for any reason, ever
a. been suspended, dismissed, terminated, resigned or withdrawn from a medical school or
postgraduate training (PGT) program?
b. been placed on probation or remediation by a medical school or PGT program?
c. taken a leave of absence or break from, had any interruption to, or any extension of a medical
school or PGT program (reasons might include illness, disability, pregnancy or parental leave,
academics, military service)?
Yes
Yes
Yes
No
No
No
Privileges/Appointments
5. a. For any reason, have your privileges at any healthcare entity ever been subject to
investigation, which resulted in a voluntary or involuntary restriction, reduction, suspension,
surrender, revocation, or non-renewal of your privileges?
b. Have you ever agreed to limit or not to exercise your clinical privileges while under
investigation?
Yes
Yes
No
No
6. Have you ever been disciplined or suspended by any healthcare entity with which you have
been employed, or resigned in lieu of investigation or other action?
Yes
No
7. Have you ever been subject to a request for corrective action by a healthcare entity where
you held appointment as a member of the medical staff?
Yes
No
Insurance/Health Care Plans
8. Has any private or government health plan or network, e.g., a private healthcare insurance
provider, Medicare, Medicaid, ever limited, sanctioned, or terminated you as a provider?
Yes
No
Liability
New Mexico Medical Board Uniform Application Addendum 1
Revised: September 2021 Page 5 of 5
9. Has your professional liability coverage ever been terminated by action of the insurance
company, except as a result of the company ceasing to offer insurance to physicians?
Yes
No
10. Have you ever been denied professional liability insurance coverage?
Yes
No
11. Has your professional liability insurance carrier ever excluded any procedures from your
coverage?
Yes
No
12. Within the past ten (10) years, have you ever been involved in a public or private settlement,
or a medical malpractice claim or suit, or been notified in writing of the intent to file a malpractice
suit? If yes, please complete the attached Malpractice History form (link to form) for each
case.
Yes
No
13. Have you ever been reported to the National Practitioner Data Bank (NPDB)?
Yes
No
Ethics/Impairment
14. Regardless of the outcome and the status of the proceeding, have you ever been arrested
or named as a defendant in any criminal action, e.g., convicted, acquitted, dismissed, vacated,
sealed, expunged, appealed?
Yes
No
15. a. During the past five (5) years, have you engaged in any behavior(s) or used any
substance(s) (e.g., alcohol, street drugs, prescription medications) in a manner characteristic
of an addiction disorder?
b. Are you now engaging in any behavior(s) or using any substance(s) (e.g., alcohol, street
drugs, prescription medications) in a manner characteristic of an addiction disorder?
c. Have you been diagnosed with or treated for an addiction disorder at any time during the
past five years (including the present)?
Yes
Yes
Yes
No
No
No
16. Are you now, being treated with any opioid analgesic(s) for chronic pain? If yes, please
provide a current neuropsychological evaluation and written clearance to practice from your
treating physician. See Rule 16.10.14.10.
Yes
No
17. Do you have, or have you been diagnosed with, an illness or condition which impairs your
judgment or affects your ongoing ability to practice medicine in a competent, ethical, and
professional manner? If yes, please have your treating physician send the NM Medical
Board a letter regarding your diagnosis, treatment, and current status.
Yes
No
18. Are you currently out of compliance with a judgment and order for child support in New
Mexico?
Yes
No
Attestations
19. I attest I will limit my practice to areas in which I am competent to practice.
Yes
No
20. I attest I understand I have a continuing duty to report any adverse action taken against me
or my license as required by Board Rule Part 16.10.10 NMAC.
Yes
No
21. I attest I have reviewed the completed form and the information it contains is complete and
accurate.
Yes
No
22. I attest I have provided a reliable and reasonable address for correspondence to be sent
to me by the Board and will notify the Board of any address changes.
Yes
No
23. I attest I will adhere to AMA’s ethical standards and the principles of professionalism,
honesty, and respect for the law at all times.
Yes
No
If you answered “YES” to questions 1-18, and/or “NO” to questions 19-23,
please provide a detailed written explanation for each of those answers with this application.
_______________________________________________________________
Applicant Name _____________________________________________ Date____________________________
Page 7
New Mexico Medical Board Uniform Application Addendum 2
Revised: September 2021 Page 1 of 1
New Mexico Medical Board
2055 S. Pacheco St.
Building 400
Santa Fe, NM 87505
(505) 476-7220
PROFESSIONAL RECOMMENDATION
The New Mexico Medical Board requires the completion of this Professional Recommendation by a physician or a Chief of Staff or a Department
Chief with whom I have worked and who has personal knowledge of my character and competence to practice medicine. This form is required as part
of my application for licensure. All elements in the section below must be completed. The lower half of the form may be used for narrative comment.
This is my authorization to send this completed form and release all information in your files, favorable or otherwise, DIRECTLY to the NMMB, 2055
S. Pacheco St., Bldg. 400, Santa Fe, NM 87505.
Applicant’s Name:________________________________________________________ Date of Birth ______/______/_________
Applicant’ Signature: ________________________________________________________ Date_____________________________
Address: ________________________________________________ City ____________________________State_____ Zip _______
ALL ELEMENTS IN THIS SECTION MUST BE COMPLETED BY THE RECOMMENDING PHYSICIAN
The information on this form is NOT a public document.
1. Date and type of service: This individual served with me as _________________________________________________________
from ___________________ to _______________________ at ________________________________________________________
Month/Year Month/Year Location
2. Please evaluate: (Please indicate with check mark)
Poor
Fair
Good
Superior
Professional knowledge
Clinical judgment
Relationship with patients
Ethical/professional conduct
Ability to communicate
Clinical skills
3. Recommendation: (please indicate with a check mark)
1. Recommend highly and without reservation
2. Recommend as qualified and competent
3. Recommend with some reservation (explain)
4. Concerns (explain)
4. Of particular value in evaluating the candidate is information regarding any notable strengths and weaknesses (including personal demeanor).
We would appreciate your comments.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
5. The above report is based on: (please indicate with check mark)
1. Close personal observation
3. A composite of evaluations
2. General impression
4. Other
Name (Please Print): _________________________________Title: ________________________Phone: ________________
Signature: _______________________________________________________ Date: _________________________________
New Mexico Medical Board Uniform Application Addendum 3
Revised: September 2021 Page 1 of 1
New Mexico Medical Board
2055 S. Pacheco St.
Building 400
Santa Fe, NM 87505
(505) 476-7220
WORK EXPERIENCE VERIFICATION
I am applying for a medical license in the State of New Mexico. The New Mexico Medical Board requires this form to be completed by
the Chief of Staff or facility’s administrative staff. I hereby authorize release of all information in your files, favorable or otherwise,
DIRECTLY to the NMMB, 2055 S. Pacheco St., Bldg. 400, Santa Fe, NM 87505.
Applicant Name
Applicant Signature
Address
*Dates of Privilege/Employment mm/yy to mm/yy (must be provided)
City/State/Zip
Telephone Number
The section below should be completed by the chief of staff or facility’s administrative staff. Letters of
Recommendation are NOT accepted in lieu of this form.
Type or Print Name of person completing this form
Title
Name of Institution
Address
City / State / Zip
1. This evaluation is based on: ___Observation of applicant ___Review of personnel file
2. In your estimation, is there any reason why this applicant should not be licensed to practice? ___Yes ___No
3. To your knowledge, is there any mental or physical reason why this applicant should not be licensed? ___Yes ___No
4. To your knowledge, is there any derogatory/disciplinary information regarding this applicant? ___Yes ___No
5. Are the dates of privilege/employment provided by the applicant on this form accurate?* ___Yes ___No
*If not, please provide correct dates: Beginning _____________________ Ending _____________________
Month/Year Month/Year
If you answered “YES” to questions 2, 3, and/or 4, please provide a written explanation and/or any supporting
documentation that may be relevant.
___________________________________________________________________________________________________
Printed name of person completing this form Signature Date
___________________________________________________________________________________________________
Signature of Notary (if applicable) Date
My commission expires: _______________________________________________________________________________
Please note on this form if there is no hospital or notary seal available.
Please return this form directly to the address above.
Thank you for your cooperation.
Please affix hospital or
notary seal here
New Mexico Medical Board
2055 S. Pacheco St. Bldg. 400
Santa Fe, NM 87505 (505) 476-7220
I, ____________________________________________, hereby certify that I am the person
pictured below and named in this application for a license to practice as a Physician in the
State of New Mexico; that all statements I have made herein are true; that I am the original
and lawful possessor and person named in the various forms and credentials furnished to
the New Mexico Medical Board (Board) with my application.
I acknowledge and state that I have read the Information and Instructions that accompanied this
application and I have answered all questions truthfully. I understand that the fee I submitted is not
refundable.
I authorize and request every person, hospital, clinic, community, governmental agency, court,
association, institution or other organization having control of any documents, records, and other
information pertaining to me, to furnish to the Board any such information, including documents,
records regarding charges or complaints filed against me, formal or informal, pending or closed, or
any other pertinent data and to permit the Board or their agents or representatives to inspect and
make copies of such documents, records and other information, in connection with this application.
I hereby release, discharge, and exonerate the Board, and their agents or representatives, and any
person furnishing information, from any and all liability of every nature and kind arising out of the
furnishing or inspection of such documents, records, other information, or the investigation made by
the Board. I authorize the Board to release information, material, documents, orders, or the like
relating to me or to this application to any other agency of the State of New Mexico or the
appropriate licensing agency of any other state or Territory of the United States or any agency of the
United States government.
*Passport-quality color photograph taken within six months prior to filing the application, approximate size 2 x 2 inches,
head and shoulders only, full face, front view, plain white or off-white background, standard photo stock paper, scanned
or computer-generated photographs should have no visible pixels or dots.
____________________________________________________________________
Applicant Name _______________________________________________ Date ____________________________
ATTACH
RECENT
PASSPORT-
QUALITY*
PHOTOGRAPH
THAT WILL FIT IN
THIS SPACE
________________________________________________________
Applicant Signature Date
APPLICANT’S OATH
New Mexico Medical Board
2055 S. Pacheco St.
Building 400
Santa Fe, NM 87505
(505) 476-7220
VERIFICATION OF LICENSURE
I am applying for medical licensure in the State of New Mexico. The New Mexico Medical Board requires that your Board
complete this form or its equivalent so that I may be considered for licensure. This is my authorization to release all
information in your files, favorable or otherwise, to the NMMB,
2055 S. Pacheco St., Bldg. 400, Santa Fe, NM 87505
Print/Type Full Name
Signature Date
License Number Date Issued
Address
City State Zip Code
THE SECTION BELOW SHOULD BE COMPLETED BY THE MEDICAL BOARD
Name of Licensing Authority: _______________________________________________________________________
Name of Licensee: _______________________________________________________________________________
License Number: ____________________ Issue Date: __________________ Expiration Date: __________________
1. Is license current? ___Yes ___No If “No” why not? __________________________________________________
2. Did you receive source documents verifying: Education? ___Yes ___No
Postgraduate Training? ___Yes ___No
Examination? ___Yes ____No
3. Has licensee ever been disciplined by your Board? ____Yes ____No
If “Yes”: Revoked ___Yes ___No Suspended ___Yes ___No
Stipulated ___Yes ___No On Probation ___Yes ___No
Dates:___________________________________________________________
4. Has his licensee’s license ever been: Allowed to lapse for non-payment of fees? ___Yes ___No
Placed on Retired or Inactive status? ___Yes ___No
Surrendered Voluntarily ? ___Yes ___No
5. Are there any formal charges pending against this license? ___Yes ___No
6. Has licensee ever been investigated or requested to appear before your Board for any serious matter? ___Yes ___No
If you answered “YES” to questions 3-6 please provide a written explanation below, and attach a copy
of all supporting documentation (e.g., Board order, complaint, etc.).
________________________________________________________________________________________________
________________________________________________________________________________________________
Please Affix
Board Seal Here
___________________________________________________________________________________________________
Signature of Board Official Date
______________________________________________________________ ___________________________________
Title Phone Number
New Mexico Medical Board
2055 S. Pacheco St.
Building 400
Santa Fe, NM 87505
(505) 476-7220
MEDICAL EDUCATION VERIFICATION
APPLICANT INSTRUCTIONS: Please complete the waiver for release of information and forward this form to your
university/medical school(s) or university of graduation for verification.
Waiver for Release of Information
I authorize the medical school/university listed below to provide any and all information pertaining to my medical
education at your institution.
Applicant’s Signature:_________________________________________Date of Birth ________/_______/______
Print or Type Name: ______________________________________Soc Sec # ____________________________
Other Name(s) _______________________________________________________________________________
Name of Medical School: _______________________________________________________________________
Address: _____________________________________City _____________________State_______ Country_______
DEAN OR DESIGNATED OFFICIAL OF MEDICAL SCHOOL INSTRUCTIONS:
Please complete this form and forward it DIRECTLY to NMMB, 2055 S. Pacheco St., Bldg. 400, Santa Fe, NM 87505.
Please include dean’s letter (if available) and a COPY OF THE OFFICIAL TRANSCRIPT (which indicates courses taken,
dates and hours of attendance, and scores, grades, or evaluations).
APPLICANT’S EDUCATIONAL DEGREE AND DATE AWARDED HISTORY
If name of institution was different from the above named institution when applicant attended, please enter name below:
_______________________________________________________________________________________________
Enrollment and Participation: Our records indicate that
______________________________________________________________________________________________,
(type or print the applicant’s name): (Last Name) (First Name) (MI)
attended our medical school on the following dates (indicate the month, day and year in the section below):
ATTENDANCE DATES: FROM TO FROM TO
____/____/____ ____/____/____ ____/____/____ ____/____/____
____/____/____ ____/____/____ ____/____/____ ____/____/____
____/____/____ ____/____/____ ____/____/____ ____/____/____
The applicant attended _____ total weeks of continuing on-campus education, not less than 32 weeks in each academic
year and:
Check One ____Was awarded a degree in __________________________ on _____/______/______
mm dd yr
____Was NOT awarded degree. Please explain reasons(s):___________________________
________________________________________________________________________________________________
______________________________________________________________________________________________
Page 1 of 2
Unusual Circumstances: The following questions apply to unusual circumstances that occurred during any part of the
applicant’s medical education. All questions must be answered.
If you answer “YES” to any of the questions
below, please enclose an explanation.
1. Did the applicant take any leaves of absence or breaks from his/her medical education? ___Yes ___No
2. Was the applicant ever placed on probation? ___Yes ___No
3. Was the applicant ever disciplined or under investigation? ___Yes ___No
4. Were any negative reports ever filed by instructors regarding the applicant? ___Yes ___No
COMMENTS:_____________________________________________________________________________________
________________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________________________________________________
AFFIX INSTITUTIONAL SEAL HERE
Signature: ________________________________________
Print Name: ______________________________________
International medical schools must attach a copy Title: ____________________________________________
of the medical school diploma and a transcript or
provide and explanation. Date: ___________________________________________
This form will not be accepted unless it is stamped with the institutional seal.
Thank you for helping us process this application for licensure.
New Mexico Medical Board
2055 S. Pacheco St.
Building 400
Santa Fe, NM 87505
(505) 476-7220
POSTGRADUATE TRAINING VERIFICATION
I am applying for a license to practice medicine in New Mexico and the Medical Board requires this form to be completed by each
hospital where I participated in an approved postgraduate training program in the United States or Canada. This is your authorization
to release any information in your files of record, favorable or otherwise, DIRECTLY to the NMMB, 2055 S. Pacheco St., Bldg. 400,
Santa Fe, NM 87505. Your prompt response will be appreciated.
Name: ___________________________________________________________________________________ M.D.
Signature Date (Month/Day/Year)
(DO NOT DETACH)
This section to be completed by the office of the Administrator of the institution or program wherein the applicant satisfactorily
completed (or will complete) an approved postgraduate training program in the United States or Canada.
This is to certify that ___________________________________________________, undertook and satisfactorily completed
a full term approved program of ________months in the ___________________________________________________________
(number) (Full name and complete address of facility)
in the field of _____________________________________________from _____________________to _____________________.
Date: Mo/Day/Yr Date/Anticipated Date Mo/Day/Yr
1. Was this program approved for postgraduate training during that period by the Accreditation Council for Graduate Medical
Education, or the Royal College of Physicians and Surgeons of Canada? ____Yes ____No
2. Was applicant ever placed on probation, restricted, or limited? _____Yes _____No If yes, please attach written explanation.
3. Was there any reason not to continue applicant in the training program? _____Yes _____No If yes, please attach written
explanation.
4. Did the applicant have any medical condition, which in any way impaired or limited his/her ability to safely practice any field of
medicine? ____Yes ____ No If yes, please attach written explanation.
Ability to practice medicine is to be construed to include all the following:
The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned medical judgments
and to learn and keep abreast of medical developments; and
The ability to communicate those judgments and medical information to patients and health care providers,
with or without the use of aids or devices, such as voice amplifiers; and
The physical capability to perform medical tasks such as physical examination and surgical procedures,
with or without the use of aids or devices, such as corrective lenses or hearing aids
"Medical condition" includes physiological, mental or psychological conditions or disorders, such as, but
not limited to orthopedic, visual speech, and hearing impairments, cerebral palsy, epilepsy, muscular
dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional or mental
illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction and alcoholism.
5. Was the applicant ever diagnosed with or treated for bipolar disorder, schizophrenia, paranoia, or any psychotic
disorder? ____Yes ____No If yes, please attach written explanation.
6. Were applicant's final evaluations in every category rated satisfactory? ____Yes ____ No If no, please attach written
explanation.
Please affix hospital or
notary seal here
___________________________________________________________________________________________________
Printed name of person completing this form Signature Date
___________________________________________________________________________________________________
Signature of Notary (if applicable) Date
My commission expires:_______________________________________________________________________________
If there is no hospital or notary seal, this form is unacceptable.
Please return this form directly to the address above
Thank you for your cooperation.