Instructions for Assistant Physician Application

Attached are the materials you will need to make application for licensure to practice as an assistant physician in the State of Missouri.
It is suggested that you read this Instructions sheet before beginning the process.

Your Application Packet Consists of:

 These instructions;  Postgraduate Reference Letter Form;

 Application;  Hospital Affiliation Verification Form;
 Licensure Verification Form;  Malpractice Claim Form;
 Official Documents Form (International graduates only);  Armed Forces of the United States Form.

Prior to completing the application, you should read the statutes and rules governing assistant physicians in the State of
Missouri. These are located on our website at http://pr.mo.gov/healingarts-rules-statutes.asp.

GENERAL INFORMATION
In addition to the materials you are required to submit, the Board makes independent inquiries into your background. You should allow
a minimum of 30 days for the processing of your application once the Board has received all documents. When your application is
received and processed, you will be notified via email of how to check the status of your application online. Additionally, the Board can
request that you appear before them prior to issuing your license.

All assistant physician licenses expire on January 31. Please remember this date so you can allow time for your renewal to be
processed. Information on renewing your license will be mailed to you on or before December 1 of each year to the last known address
on file. Failure to receive the renewal application does not relieve any person of the duty to register and pay the fee required for renewal
nor exempt them from the penalties for failure to renew. Therefore it is imperative that you notify the Board of any address change
as soon as it occurs. If your license expires, you cannot practice in Missouri until your renewal is granted.

FEE
The fee for a license is $25. Please make checks payable to the Missouri Board of Healing Arts. All checks must be drawn on a
United States bank because our bank doesn’t accept checks from International banks. No application will be processed until the fee is
received. The Board cannot accept credit or debit cards for payment of the initial application fee.

ARMED FORCES OF THE UNITED STATES

If you have you ever served on active duty in the Armed Forces of the United States and separated from such service under conditions
other than dishonorable; or if you are the spouse of an active duty member of the Armed Forces of the United States, you may qualify
for additional services. If applicable, please complete the form included in the application and return it with your application, along with
verification of military status.

ACTIVITIES STATEMENT
 Please provide all medical and nonmedical activities since graduation from your medical/doctorate program, or from the last 10
years, whichever is less, to the present date in CHRONOLOGICAL ORDER.
 All dates must be accounted for in the MM/YYYY format.
 Please include complete names and addresses for each activity listed.
 If unemployed or on vacation for at least a month, list your exact activities.
Note: if there are dates not accounted for, you will be contacted by the Board to account for those dates.

INFORMATION TO SUBMIT IF ANY OF THE PERSONAL HISTORY QUESTIONS ARE ANSWERED YES
 Questions 1-9 - Include a separate statement/letter explaining the circumstances behind your “yes” answer. Documentation
supporting your statement, if applicable (i.e. a settlement agreement from another state disciplining your license, documents
showing probation in your postgraduate program, etc.) needs to be submitted directly from the state board, hospital, etc.
 Question 10 - Include a separate statement/letter explaining the circumstances behind your “yes” answer and also submit a
certified copy of the court records or have your attorney send the documents to the Board. The Board needs to receive a copy
of the complaint/petition and judgment, settlement, or disposition.
 Question 11 - Include a separate statement/letter explaining the circumstances behind your “yes” answer along with a copy of
the charge (it may be called a petition, indictment, information, or complaint), and the judgment, sentence, or dismissal order,
certified by the court or from your attorney.
 Question 12 - Include a separate statement/letter explaining the circumstances behind your “yes” answer and documentation
supporting that statement.
 Question 13 – Please provide details and dates, including the names and addresses of the individuals and facilities which
have treated you. Also please submit a letter from your current physician or treatment professional indicating your diagnosis,
prognosis, and if your illness or condition affects your ability to practice.
 Question 14 - Please complete the Malpractice Claim Information form in its entirety. Additional documentation may be
required after review of the information provided. Please also list the number of claims in which you have been named
in the space provided

DOCUMENTS THAT NEED TO BE SUBMITTED

 Proof of Residency/Citizenship of the United States - A copy of your birth certificate, United States passport, visa, or other
United States government document evidencing legal resident status.
 Copy of Examination Scores - Your examination scores need to be sent directly to the Missouri Board of Healing Arts.
Please see below for specific instructions regarding the different licensing examinations.
  USMLE: Request an official transcript at https://portal.fsmb.org/MyFsmb/. For assistance, call 817-868-4041 or email
usmle@fsmb.org.
 NBME: Request your scores at http://www.nbme.org/Cert-tran/Scores-and-transcripts.html. For assistance, call
215-590-9500 or email scores@nbme.org.
 NBOME/COMLEX-USA: Request a certified copy of your official transcript at http://www.nbome.org/transcript-
request.asp?m-can. For assistance, call 866-479-6828 or email Client Services
at http://www.nbome.org/contactform.asp?m=inf.
 LMCC: Complete the Service Request form at http://mcc.ca/forms/certified-transcript-examinations/. For
assistance, call 613-521-6012 or email service@mcc.ca.

 National Practitioner’s Data Bank Self-Query – Contact the National Practitioner’s Data Bank (NPDB) at 1-800-767-6732 or
http://www.npdb.hrsa.gov/index.jsp and perform a self query. When you receive your self-query, forward the original
information to the Board by email (licensure@pr.mo.gov), fax (573-751-3166) or mail.
 Medical Diploma - A copy of your medical diploma (not larger than 8 ½” x11”) - OR - Medical Transcripts – Official FINAL
transcripts with school seal affixed and degree awarded, from any medical or osteopathic school you attended. The Board can
accept electronic transcripts if they are official transcripts and sent directly from the school.
 Postgraduate Reference Letter –The director of each training program you have participated in must submit a Postgraduate
Reference Form or letter directly to the Board. One copy of this form is included in the application packet. Please print/make
additional copies as necessary.
 Hospital Affiliation Form – Each hospital where you have held active admitting privileges in the US or Canada in the last five
years must submit this form. This does not include training hospitals. Please have the hospital submit the form directly to the
Board.
 Name Change – If you have had a name change for any reason, submit copies of the document evidencing the name change
(Marriage Certificate, Divorce Decree, Adoption Order, Court Order). If the name change is due to naturalization, you must
bring the document to the office as it is illegal to copy the Naturalization Certificate.
 Verification of Licensure – If you have ever held a permanent, temporary or institutional license, permit or certificate in any
state, territory or country to practice as a physician, dentist, nurse, physician assistant, or any other professions in which a
license, permit or certificate was issued, the licensing agency must submit a verification of each to our office. The verification
must be submitted directly from the licensing agency to our office. Some licensing agencies use a secure online verification
portal however it is your responsibility to contact the licensing agency and advise them you are applying for a Missouri license.
The Board accepts verifications from VeriDoc.
 Photograph – A recent photograph must be attached to the application in the space provided. Please glue or tape your photo
- do not staple or paperclip.

HOW TO CHECK THE STATUS OF YOUR APPLICATION

When your application is received and processed, you will be notified via email of how to check the status of your application online.

NOTICE
All persons receiving a license from, or renewing a license with the Division of Professional Registration, are required to have paid all
Missouri state income taxes, and also are required to have filed all necessary Missouri state income tax returns for the preceding three
years. If you have failed to pay your Missouri taxes or have failed to file your Missouri tax returns, your license will be subject to
immediate suspension within 90 days of being notified by the Missouri Department of Revenue of any delinquency or failure to file.

ADDITIONAL INFORMATION FOR INTERNATIONAL GRADUATES

 Missouri law (section 324.024, RSMo) requires submission of your social security number. If you are a citizen of a foreign
country and do not have a social security number, you are required to submit your visa or passport number in lieu of the social
security number. This same law requires a social security number in order to renew your Missouri license.
 If you are sending original documents and need them to be returned, please fill out the “Official Documents Form.”
 Provide proof of licensure in the country you graduated from, if applicable.
 ECFMG Certification Status Report: Request a Status Report to be sent to the board you are applying to for licensure
at https://cvsonline2.ecfmg.org/. For assistance, call 215-386-5900 or email credentials@ecfmg.org.
 Transcripts and other documents must be translated into English by:
 A professor of a language department in a college or university in the United States, or The United States Embassy or
Consulate in a foreign country.
 The translator must include documentation certifying that the document is a true translation to the best of their knowledge,
and they are fluent in the original language and qualified to translate the document into English. The translator must sign
the translation and print their name and address on the translation.
If you have questions after reading these instructions, you may call the Board office at 573-751-0098 or toll free at 866-289-5753 or
email at licensure@pr.mo.gov.
 sTaTe board of regisTraTion for The healing arTs
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sTaTe of missouri jefferson ciTy, mo 65102
for overnighT deliveries
division of professional regisTraTion 3605 missouri blvd.
sTaTe board of regisTraTion for The healing arTs jefferson ciTy, mo 65109

APPLICATION FOR ASSISTANT PHYSICIAN LICENSURE

Telephone (573) 751-0098
Toll free (866) 289-5753
faX (573) 751-3166
INSTRUCTIONS
complete each section by providing complete details in black ink or by typed responses. failure to answer all questions could result in delayed processing of
your application. if additional responses are necessary, submit in a separate statement.

IMPORTANT - MINIMUM LICENSURE REQUIREMENTS

in addition to other requirements, section 334.036.1 requires the following criteria to be met for licensure as an assistant physician.
334.036.1(1) "assistant physician", any medical school graduate who:
(a) is a resident and citizen of the united states or is a legal resident alien;
(b) has successfully completed step 2 of the united states medical licensing examination or the equivalent of such step of any other board-approved
medical licensing examination within the three-year period immediately preceding application for licensure as an assistant physician, or within three
years after graduation from a medical college or osteopathic medical college, whichever is later;
(c) has not completed an approved postgraduate residency and has successfully completed step 2 of the united states medical licensing examination
or the equivalent of such step of any other board-approved medical licensing examination within the immediately preceding three-year period unless
when such three-year anniversary occurred he or she was serving as a resident physician in an accredited residency in the united states and
continued to do so within thirty days prior to application for licensure as an assistant physician; and
(d) has proficiency in the english language.
any medical school graduate who could have applied for licensure and complied with the provisions of this subdivision at any time between august 28, 2014,
and august 28, 2017, may apply for licensure and shall be deemed in compliance with the provisions of this subdivision.

A. MISSOURI TAX COMPLIANCE

•
check this box if in all of the last three years:

•
you were not a missouri resident;

•
you did not have any missouri income; and
you are not subject to any type of missouri income tax.
pursuant to section 324.010 rsmo, all persons applying for and renewing a license with the division of professional registration are required to have paid all
missouri state taxes and are also required to have filed missouri state income tax returns for the last three years. if such licensee is delinquent on any missouri
state taxes or has failed to file missouri state income tax returns in the last three years, your license will be subject to suspension within 90 days after being
notified by the missouri department of revenue of such delinquency or failure to file.
false statements are subject to criminal penalties and/or license discipline. for tax questions, please contact the department of revenue at (573) 751-7200
or email at income@dor.mo.gov.
B. IDENTIFYING INFORMATION
print your full name, mailing address, and personal information.
lasT name firsT name middle name maiden name suffiX x md
do
Wang Chunlei
oTher names used conTacT phone number business phone number
443-538-9899
sTreeT address ciTy sTaTe zip
3280 W Springs Dr. Ellicott City MD 21043
email address cerTificaTion
windsound.wang@gmail.com ECFMG
daTe of birTh place of birTh ssn gender
03/23/1977 Zhangjiagang, China 494-27-1297 M
C. COLLABORATING PHYSICIAN INFORMATION

lasT name firsT name middle name license number

collaboraTing sTreeT address ciTy sTaTe zip

collaboraTing Telephone number e-mail address

specialTy/board cerTificaTion

mo 375-1002 (7-17) page 1

D. NAMES OF INDIVIDUALS WITH WHOM THE BOARD IS AUTHORIZED TO DISCUSS YOUR FILE
conTacT #1 name conTacT #1 email conTacT #1 Telephone number

conTacT #2 name conTacT #2 email conTacT #2 Telephone number

approximate date that a missouri license is needed: _____________ The board will process your application as quickly as possible but be
advised that your application, fee and supporting documentation needs to be received and approved prior to issuing a missouri license.
Issuance of a Missouri license is required prior to practicing in the State of Missouri. sometimes applications require additional review
by board members and this can delay the decision on whether or not a missouri license is issued.
E. PREMEDICAL EDUCATION
list the name of each school, city and state, dates of attendance, degree awarded and dates degree was awarded from all colleges attended.
FROM TO DEGREE DATE
NAME AND LOCATION OF SCHOOL
MONTH YEAR MONTH YEAR AWARDED AWARDED

F. MEDICAL/DOCTORATE EDUCATION
list the name of each school, location, dates of attendance, degree awarded and dates degree awarded from all colleges attended. if it took
longer than four years to complete medical school, please explain.

FROM TO DEGREE DATE

NAME AND LOCATION OF SCHOOL
MONTH YEAR MONTH YEAR AWARDED AWARDED

G. EXAMINATION
have you previously Taken The

fleX    yes  no usmle    yes  no naTional boards    yes  no

lmcc    yes  no sTaTe boards yes  no comleX    yes  no
if yes, indicate the number of times you have taken each portion of the examination and the dates they were taken in the space below.

Part 1/Step 1/Level 1 Part 2/Step 2(CK)/Level 2(CE) Part 2/Step 2(CS)/Level 2(PE) Part 3/Step 3/Level 3 Component 1 Component 2

H. ACGME/AOA/CANADIAN ROYAL COLLEGE OF PHYSICIANS AND SURGEONS POSTGRADUATE EXPERIENCE

list acgme/aoa/canadian royal college of physicians and surgeons postgraduate training received in the united states and canada by
indicating the type of training received, name of hospital, address and the department/specialty, beginning and ending dates, and program director.
1.hospiTal name

intern      resident      fellow      research      other

address ciTy, sTaTe, zip

deparTmenT/specialTy Term sTarTed (monTh/year) Term compleTed (monTh/year)

program direcTor name accrediTed by

acgme      aoa      royal college      other _______________________

mo 375-1002 (7-17) page 2
2.hospiTal name

intern      resident      fellow      research      other

address ciTy, sTaTe, zip

deparTmenT/specialTy Term sTarTed (monTh/year) Term compleTed (monTh/year)

program direcTor name accrediTed by

acgme      aoa      royal college      other _______________________

I. HOSPITAL AFFILIATION ADMITTING PRIVILEGES ONLY
list all united states and/or canadian hospitals in which you had admitting privileges for the last five (5) years. indicate the name,
address and dates of privileges, excluding all training programs. if you have additional hospitals, please list them separately.
DATE OF PRIVILEGES
HOSPITAL NAME ADDRESS CITY AND STATE
TERM STARTED TERM COMPLETED
(monTh/year) (monTh/year)

(monTh/year) (monTh/year)

(monTh/year) (monTh/year)

J. ECFMG CERTIFICATION
ecfmg cerTificaTion number issue daTe

K. OTHER PROFESSIONAL LICENSES HISTORY

list all other professional licenses, registration or certifications you now hold or have ever held (e.g. physician assistant, registered nurse, etc.)
PROFESSION STATE IN WHICH HELD PROFESSION STATE IN WHICH HELD

L. ACTIVITIES
chronologically list all medical and nonmedical activities since graduation from your medical/doctorate program or from the last 10 years,
whichever is less, to the present date. please account for all months.
DATES
ACTIVITY ENTITY NAME & ADDRESS CITY & STATE COUNTRY
BEGINNING ENDING
MONTH/YEAR MONTH/YEAR

mo 375-1002 (7-17) page 3

M. PERSONAL HISTORY
answer the following questions with the appropriate checkmark. If any are answered yes, see the Instruction Sheet for specific
information and documentation needed for review.

1. have you been denied a license, registration or certificate to practice as a physician or any other profession or been
denied the privilege of taking an examination administered by a u.s. state, canadian provincial or international licensing
agency? yes    no

2. have you made application for licensure, registration or certification in another state, province or country and
subsequently withdrawn said application? yes    no

3. has any license or right to practice held by you been disciplined, including but not limited to restriction, revocation,
suspension, probation, censure, or reprimand, whether voluntarily agreed to or not, by any u.s. state, territory, federal
agency, canadian province or foreign country? yes    no

4. have you had any disciplinary or corrective action taken against you, or had your right to practice restricted, by any
professional medical or osteopathic association or society, or by any licensed hospital or medical staff of a hospital
including being placed on probation while in a postgraduate training program? yes    no

5. have you ever been restricted, suspended, terminated, requested to voluntarily resign, placed on probation, counseled,
received a warning or been subject to any remedial or disciplinary action during medical school or a postgraduate
training program? yes    no

6. have you surrendered a license issued to you by any u.s. state or any canadian provincial licensing agency for any
reason, other than failure to renew, retirement or relocating to another state? yes    no

7. have any charges or complaints been filed against you with the federal government, any federal agency or any u.s.
state or canadian provincial licensing or disciplinary agency? yes    no

8. have you been denied or surrendered a controlled substance license, registration, certificate or authority issued by the
drug enforcement administration (dea) or any state bureau of narcotics or other agency concerned with controlled
substances, or had such license, registration, certificate or authority restricted or disciplined, including, but not limited
to, revocation, suspension, probation, censure, or reprimand, whether voluntarily agreed to or not? yes    no

9. has any disciplinary action been taken against you, or has your authority to practice been restricted, by any federal or
state agency including, but not limited to, medicare or medicaid? yes    no

10. have you forfeited collateral for breach or violation of any law, police regulation or ordinance whatsoever, been
summoned into court as a defendant, or has any lawsuit (other than malpractice) been filed against you? yes    no

11. have you been arrested, charged, indicted, found guilty, or entered a plea of guilty, an alford, no contest plea or plea of
nolo contendere, in a criminal prosecution in any state, federal, or municipal court whether or not sentence was imposed,
including suspended imposition of sentence or suspended execution of sentence, except for minor traffic violations?
alcohol related traffic violations must be reported. yes    no

12. have you been required by federal law or the law of any state to register as a sex offender? yes    no

13. do you currently have any condition or impairment which in any way affects your ability to practice in a professional,
competent and safe manner, including but not limited to: (1) a mental, emotional, nervous or sexual disorder, (2) an
alcohol or substance abuse disorder or (3) a physical disease or condition? yes    no

14. have you been a defendant in a legal action involving professional liability (malpractice) or had a professional liability
claim paid in your behalf or paid such a claim yourself? yes    no

14a.if your answer is yes, please indicate how many claims in which you have been named. ______

mo 375-1002 (7-17) page 4

N. APPLICANT’S OATH

during the period of time in which the board is processing my application and determining whether to issue me a license, i will inform
the board of any change in information included in my application for licensure, including but not limited to address updates, malpractice
suits, discipline imposed by another state, administrative agency, hospital or other entity, arrests, and criminal convictions. i understand
that failure to disclose this information could result in discipline pursuant to sections 334.036 and 334.100, RSMo.

i hereby certify under oath that i am the person named in this application for a license to practice as an assistant physician in the state
of missouri; that all statements i have made herein are true and that i have personally read, reviewed and answered each of these
questions; that all documents submitted with this application or as part of the application process that are original, or duplicated copies
of the originals, have not been altered in any fashion whatsoever; that i am the original and lawful possessor of and person named in
the various documents and credentials furnished to the board in connection with this application. i acknowledge and state that i have
read the missouri statutes and rules governing the practice as an assistant physician, that are located on the board’s website; i have
answered all questions truthfully and in compliance with the instructions provided; and i understand that the application fee submitted
with this application is non-refundable and cannot be transferred to another application.

i further certify that i will not practice as an assistant physician in the state of missouri unless and until a license is granted, and that i
will not practice or attempt to practice without an assistant physician collaborative practice arrangement, except as otherwise provided in
section 334.036, RSMo, and in an emergency situation.

i further state that by filing this application for a license to practice as an assistant physician in the state of missouri, i hereby authorize
and consent to have an investigation made as to my moral character, professional reputation and fitness for the practice as an assistant
physician, when in the opinion of the missouri board such an investigation is deemed necessary. i agree to give any further information
which may be required in reference to my past record. i authorize and request every person, hospital, clinic, community, governmental
agency (local, state, federal or international), court, association, institution or other organization having control of any documents, records
and other information pertaining to me to furnish to the missouri state board of healing arts 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 missouri state board of healing arts or any of its agents or representatives to inspect and make copies of such documents, records,
and other information, in connection with this application.

MUST BE SIGNED IN applicanT’s signaTure

PRESENCE OF NOTARY
▼

O. NOTARIZATION
sTaTe counTy

noTary public rubber sTamp

The applicant identified him/herself with a government issued photographic identification and bearing
true likeness to the attached photograph subscribed and swore to the truthfulness of this application
before me, this _____________ day of ____________________________ , _______________ .
noTary public signaTure commission eXpires noTary public embosser seal

noTary public prinTed name

please glue or Tape your phoTo To The applicaTion.

PHOTO
do noT sTaple or paper clip phoTo.

mo 375-1002 (7-17) page 5

 Jurisprudence Examination – Assistant Physician

Instructions SCORE: ______

Completion of the jurisprudence examination and achieving a scores of 75% or higher is a requirement of the Missouri
State Board of Registration for the Healing Arts. Each of the twenty true and false questions is given a weight of five
percentage points. All the answers are readily available to you in the statutes and rules that are readily available to you
in the statutes and rules that are located on the Board’s website at https://pr.mo.gov/healingarts-rules-statutes.asp.

1 T F An assistant physician is any medical school graduate who has successfully completed Step 2 of the United
States Medical Licensing Examination or the equivalent of such step of any other board-approved medical
licensing examination within the three-year period immediately preceding application for licensure as an
assistant physician, or within three years after graduation from a medical college or osteopathic medical
college, whichever is later (section 334.036.1(1)(b), RSMo).

2 T F An assistant physician is any medical school graduate who has not completed an approved postgraduate
residency and has successfully completed Step 2 of the United States Medical Licensing Examination or
the equivalent of such step of any other board-approved medical licensing examination within the
immediately preceding three-year period unless when such three-year anniversary occurred he or she was
serving as a resident physician in an accredited residency in the United States and continued to do so
within thirty days prior to application for licensure as an assistant physician. (section 334.036.1(1)(c),
RSMo).

3 T F Assistant physicians are not required to have proficiency in the English language. (section 334.036.1(1)(d),
RSMo).

4 T F An assistant physician collaborative practice arrangement shall limit the assistant physician to providing
only primary care services and only in medically underserved rural or urban areas of this state or in any
pilot project areas established in which assistant physicians may practice. (section 334.036.2(1), RSMo).

5 T F An assistant physician license cannot be suspended or revoked by the board in the same manner and for
violation of the standards as set forth by section 334.100, or such other standards of conduct set by the
board by rule. (section 334.036.3(1), RSMo).

6 T F An assistant physician is not required to identify himself or herself as an assistant physician and shall be
permitted to use the terms "doctor", "Dr.", or "doc". (section 334.036.4, RSMo).

7 T F The collaborating physician is not responsible at all times for the oversight of the activities of and does not
accept responsibility for primary care services rendered by the assistant physician. (section 334.036.5,
RSMo).

8 T F To be eligible to practice as an assistant physician, a licensed assistant physician shall enter into an
assistant physician collaborative practice arrangement and any renewal of licensure under 334.036 shall
include verification of actual practice under a collaborative practice arrangement in accordance with
334.036 during the immediately preceding licensure period. (section 334.036.6, RSMo).

9 T F Collaborative practice arrangements, which shall be in writing, may delegate to an assistant physician the
authority to administer or dispense drugs and provide treatment as long as the delivery of such health care
services is within the scope of practice of the assistant physician and is consistent with that assistant
physician's skill, training, and competence and the skill and training of the collaborating physician. (Section
334.037.1, RSMo).
10 T F It is not a requirement that there shall be posted at every office where the assistant physician is authorized
to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing
patients that they may be seen by an assistant physician and they do not have the right to see the
collaborating physician. (section 334.037.2(3), RSMo).

11 T F The written collaborative practice arrangement shall contain a description of the time and manner of the
collaborating physician's review of the assistant physician's delivery of health care services. The description
shall include provisions that the assistant physician shall submit a minimum of ten percent of the charts
documenting the assistant physician's delivery of health care services to the collaborating physician for
review by the collaborating physician, or any other physician designated in the collaborative practice
arrangement, every fourteen days. (section 334.037.2(9), RSMo).

12 T F The collaborating physician, or any other physician designated in the collaborative practice arrangement,
shall review every fourteen days a minimum of twenty percent of the charts in which the assistant physician
prescribes controlled substances. (section 334.037.2(10), RSMo).

13 T F Within thirty days of any change and on each renewal, the state board of registration for the healing arts
shall require every physician to identify whether the physician is engaged in any collaborative practice
arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled
substances, and also report to the board the name of each assistant physician with whom the physician
has entered into such arrangement. (section 334.037.5, RSMo).

14 T F A collaborating physician or supervising physician shall not enter into a collaborative practice arrangement
or supervision agreement with more than six full-time equivalent assistant physicians, full-time equivalent
physician assistants, or full-time equivalent advance practice registered nurses, or any combination
thereof. (section 334.037.6, RSMo).

15 T F No contract or other agreement shall require any assistant physician to serve as a collaborating assistant
physician for any collaborating physician against the assistant physician's will. (section 334.037.10, RSMo).

16 T F All collaborating physicians and assistant physicians in collaborative practice arrangements shall wear
identification badges while acting within the scope of their collaborative practice arrangement. The
identification badges shall prominently display the licensure status of such collaborating physicians and
assistant physicians. (section 334.037.11, RSMo).

17 T F An assistant physician with a certificate of controlled substance prescriptive authority as provided in

334.037 may prescribe any controlled substance listed in Schedule III, IV, or V of section 195.017, and
may have restricted authority in Schedule II, when delegated the authority to prescribe controlled
substances in a collaborative practice arrangement. (section 334.037.12, RSMo).

18 T F Assistant physicians may not prescribe buprenorphine for patients receiving medication assisted treatment
for substance use disorders under the direction of the collaborating physician. (section 334.037.12, RSMo).

19 T F The collaborating physician shall be responsible to determine and document the completion of at least one
hundred twenty hours in a four-month period by the assistant physician during which the assistant physician
shall practice with the collaborating physician on-site prior to prescribing controlled substances when the
collaborating physician is not on-site. (section 334.037.12(2), RSMo).

20 T F Assistant physicians are not required to hold a certificate of prescriptive authority issued by the Board.
(section 334.037.12(3), RSMo).
 sTaTe of missouri sTaTe board of regisTraTion for The healing arTs
division of professional regisTraTion p.o. boX 4, jefferson ciTy, mo 65102
for overnighT deliveries
sTaTe board of regisTraTion for The healing arTs 3605 missouri blvd., jefferson ciTy, mo 65109
ASSISTANT PHYSICIAN VERIFICATION OF Telephone (573) 751-0098

COLLABORATIVE PRACTICE ARRANGEMENT

Toll free (866) 289-5753
faX (573) 751-3166

COLLABORATING PHYSICIAN COLLABORATING ASSISTANT PHYSICIAN

physician name (prinT) assisTanT physician name (prinT)

physician license number assisTanT physician license number

Telephone number Telephone number

email address email address

COMPLETE ADDRESS OF collaboraTive pracTice locaTion(s) previous collaboraTing physician (name and license number)
*if This is a change in supervisors

specialTy/board cerTificaTion previous collaboraTing physician (name and license number)

*if This is a change in supervisors

as the collaborating physician and in accordance with chapter 334 as the collaborating assistant physician and in accordance with
rsmo and the board’s rules, i certify that: chapter 334 rsmo and the board’s rules, i certify that:

• i will be supervising the above named assistant physician for the • i will be collaborating with the above named physician,
delivery of health care services within the assistant physician’s appropriate to my training and experience and will not practice
scope of practice and consistent within each collaborating beyond the scope of my training and experience nor my
professional’s skill, training, and competence and the skill and capabilities and training; (334.037.1 and 334.037.2(5)(a))
training of myself. (334.037.1 and 334.037.2(5)(a)) • i understand the collaborative practice agreement shall meet
• i understand i am responsible at all times for the oversight of the the requirements set forth in 334.037 and 20 csr 2150-2.240
activities of and accept responsibility for primary care services such as maintaining geographical proximity, reviewing charts
rendered by the assistant physician. (334.036.5) and delegating controlled-substance prescriptive authority.

• i understand the collaborative practice agreement shall meet the • i understand the collaborative practice agreement shall limit me
requirements set forth in 334.037 and 20 csr 2150-2.240 such in providing only primary care services and only in medically
as maintaining geographical proximity, reviewing charts and underserved rural or urban areas of this state or in any pilot
delegating controlled-substance prescriptive authority. project areas established in which assistant physician may
practice; (334.036.2)
• i understand the collaborative practice agreement shall limit the
• i will notify the board of any change or termination of a
assistant physician to providing only primary care services and
collaborative practice arrangement within thirty (30) days of
only in medically underserved rural or urban areas of this state or
such occurrence; and (20 csr 2150-2.250(1)
in any pilot project areas established in which assistant physician
may practice; (334.036.2) • i have reviewed this document with the collaborating physician
listed above and have also reviewed the statutes, rules and
• i will notify the board of any change or termination of a
regulations that govern the practice of assistant physicians in
collaborative practice arrangement within fifteen (15) days of
the state of missouri, including but not limited to 334.036
such occurrence; and (20 csr 2150-2.250(1)
-334.038 and 20 csr 2150-2.200 - 20 csr 2150-2.260.
• i have reviewed this document with the above named assistant
physician and have reviewed the statutes, rules and
regulations that govern the practice of assistant physicians in
the state of missouri, including but not limited to 334.036 -
334.038 and 20 csr 2150-2.200 - 20 csr 2150-2.260.

physician signaTure assisTanT physician signaTure

daTe daTe

mo 375-1002 (7-17) page 7

 sTaTe board of regisTraTion for The healing arTs
p.o. boX 4, jefferson ciTy, mo 65102
sTaTe of missouri for overnighT deliveries
division of professional regisTraTion 3605 missouri blvd., jefferson ciTy, mo 65109
Telephone (573) 751-0098
sTaTe board of regisTraTion for The healing arTs Toll free (866) 289-5753
POSTGRADUATE REFERENCE LETTER - ASSISTANT PHYSICIAN faX (573) 751-3166

applicanT lasT name firsT name middle name suffiX ssn dob daTe

The physician named above has applied for licensure in the state of missouri. The missouri state board of registration for the healing arts requires a postgraduate reference letter
from the program director of each acgme/aoa/canadian royal college of physicians and surgeons approved training program the applicant has been in or is currently enrolled.
please provide all of the information requested on this form and return it to the address above. This information will become part of the permanent records maintained in this office.
please note that the candidate cannot receive final consideration without your cooperation.

i hereby authorize the above-named hospital, its staff or representative, to provide to the missouri state board of registration for the healing arts any and all information requested
below, whether such information is favorable or unfavorable, and i hereby release any and all liability against the below-named institution and/or person for any and all acts performed
in fulfilling this request, provided that such acts are performed in good faith and without malice. further, i request that this completed form be sent directly to the missouri state board
of registration for the healing arts, p.o. box 4, jefferson city, mo 65102.

applicanT signaTure

program direcTor name email address phone number

name of Training hospiTal address ciTy, sTaTe, zip

accrediTed by

acgme  aoa  royal college  other ___________________________________

sTarT daTe end daTe name of deparTmenT

clinical clerkship (fifTh paThWay)

inTernship

residency

felloWship

please check one of the following:

The above named applicant satisfactorily completed ________________ months of training here.

The above named applicant is on track to successfully complete ________________ months of postgraduate training at this hospital on
_________________
(daTe)
. i further certify that i will notify the missouri board of healing arts if there are any changes to the answers on this postgraduate
reference letter, prior to the completion of the postgraduate training program.
please read The folloWing and indicaTe your ansWer by a check mark in The appropriaTe boX. (if any ansWers are “yes”,
please provide compleTe deTails on a separaTe sheeT.)
1. during the time this applicant was in your training program has he/she ever been subject to any disciplinary or corrective action,
such as imposition of consultation requirements, suspension, termination, probation or remediation plan? yes no
2. at the time the applicant left your institution, were any actions instituted, in process or pending against him/her? yes no
3. do you have knowledge of any drug or alcohol dependency or abuse by the applicant during the previous ten years or know of
any emotional, mental, behavioral or nervous afflictions? yes no

please read The folloWing recommendaTions carefully and mark The appropriaTe one.

i recommend this candidate for licensure to practice medicine and surgery without any reservation.
i recommend this candidate for licensure to practice medicine and surgery with reservation.
i do not recommend this candidate for licensure to practice medicine and surgery.
IF YOU DO NOT RECOMMEND THIS INDIVIDUAL FOR LICENSURE OR RECOMMEND HIM/HER WITH RESERVATIONS, PLEASE EXPLAIN WHY. USE A SEPARATE SHEET IF NECESSARY.

please lisT The names and addresses of any oTher physicians on a separaTe sheeT of paper Who, in your opinion, should
be conTacTed regarding This candidaTe and The reason for conTacTing Them.

i aTTesT ThaT The foregoing informaTion Which i supplied is True in every respecT.
name (please prinT or Type) TiTle

signaTure daTe

4
mo 375-1002 (7-17) page 8
 sTaTe board of regisTraTion for The healing arTs
p.o. boX 4, jefferson ciTy, mo 65102
sTaTe of missouri for overnighT deliveries
division of professional regisTraTion 3605 missouri blvd., jefferson ciTy, mo 65109
Telephone (573) 751-0098
sTaTe board of regisTraTion for The healing arTs Toll free (866) 289-5753
LICENSURE VERIFICATION - ASSISTANT PHYSICIAN faX (573) 751-3166

AUTHORIZATION AND REQUEST please Type or prinT form in BLACK ink.

applicanT lasT name firsT name middle name suffiX sTaTe, TerriTory or inTernaTional counTry of:

Type of license (physician, nurse, physician assisTanT, eTc.)

i, the above named applicant, hereby authorize and request the state board named above having control of any documents,
records and other information pertaining to me, to furnish to the missouri state board of healing arts information, including
documents, records regarding charges or complaints filed against me, formal or informal, pending or closed, or any other
pertinent information.
signaTure of applicanT license number daTe

VERIFICATION - TO BE COMPLETED BY STATE LICENSING BOARD OFFICIALS

license number issue daTe eXpiraTion daTe license meThod
sTaTe board eXam fleX eXam reciprociTy naTional board
endorsemenT
oTher (specify) usmle lmcc

has disciplinary action been taken against the license? yes no

if yes, please provide complete details and send copies of all pertinent documentation.
▼

have any complaints or charges been filed, formal or informal, pending or closed? yes no
if yes, please provide complete details and send copies of all pertinent documentation.
▼

sTaTe seal sTaTe board

daTe

sTaTe board adminisTraTor

mo 375-1002 (7-17) page 9

 sTaTe board of regisTraTion for The healing arTs
p.o. boX 4, jefferson ciTy, mo 65102
sTaTe of missouri for overnighT deliveries
division of professional regisTraTion 3605 missouri blvd., jefferson ciTy, mo 65109
Telephone (573) 751-0098
sTaTe board of regisTraTion for The healing arTs Toll free (866) 289-5753
HOSPITAL AFFILIATION VERIFICATION - ASSISTANT PHYSICIAN faX (573) 751-3166

applicanT lasT name firsT name middle name suffiX daTe

hospiTal name

hospiTal address ciTy, sTaTe zip

Term sTarTed Term compleTed

i hereby authorize the above-named hospital, its staff or representative, to provide to the missouri state board of registration for the healing
arts any and all information requested below, whether such information is favorable or unfavorable, and i hereby release any and all liability
against the above-named institution and/or person for any and all acts performed in fulfilling this request, provided that such acts are per-
formed in good faith and without malice. further, i request that this completed form be sent directly to the missouri state board of registration
for the healing arts, p.o. box 4, jefferson city, mo 65102.

signaTure daTe of birTh social securiTy number*

▼

HOSPITAL ADMINISTRATOR SECTION

This section must be completed by the hospital administrator or his/her representative and returned to the missouri state board of
registration for the healing arts.

1. The above-named applicant is/has been affiliated with our hospital from ________________________ to ________________________.

2. based on past performance, would you recommend this applicant for reappointment at this hospital? yes no

3. during the stated period of time, were the practice privileges of this applicant restricted, limited, suspended, or
revoked as a result of disciplinary action? yes no

4. please submit an explanation if question 2 is answered “no” and/or 3 is answered “yes”

commenTs, if any

i solemnly sWear ThaT The above informaTion is True and accuraTe To The besT of my knoWledge.
prinT full name TiTle email address

signaTure of adminisTraTor/represenTaTive Telephone number daTe

▼

mo 375-1002 (7-17) * verificaTion purposes only page 10

 STATE BOARD OF REGISTRATION FOR THE HEALING ARTS
P.O. BOX 4, JEFFERSON CITY, MO 65102
STATE OF MISSOURI FOR OVERNIGHT DELIVERIES
DIVISION OF PROFESSIONAL REGISTRATION 3605 MISSOURI BLVD., JEFFERSON CITY, MO 65109
TELEPHONE (573) 751-0098
STATE BOARD OF REGISTRATION FOR THE HEALING ARTS TOLL FREE (866) 289-5753
OFFICIAL DOCUMENTS FAX (573) 751-3166

INSTRUCTIONS
You are required to provide our office with all official transcripts, marks, translations and other documents requested by the
Board. Please type or print form in BLACK ink.
1. NAME AS SHOWN ON APPLICATION FIRST NAME MIDDLE NAME SUFFIX DATE
LAST NAME

2. NAME SHOWN ON DOCUMENTS IF DIFFERENT FROM APPLICATION MIDDLE NAME SUFFIX

LAST NAME FIRST NAME

3. ADDRESS (STREET, CITY, STATE, ZIP) PLEASE NOTIFY BOARD OFFICE OF ANY ADDRESS CHANGE(S)

NO. OF
4. LIST EACH OFFICIAL DOCUMENT ENCLOSED PAGES

STATE OFFICE USE ONLY

DATE RECEIVED NUMBER OF ORIGINALS RECEIVED DATE RETURNED NUMBER OF ORIGINALS RETURNED

TRACKING NUMBER RETURN ADDRESS IF NOT SAME AS LISTED ABOVE INITIAL 1 INITIAL 2
 statE BoaRd of REgIstRatIon foR tHE HEaLIng aRts
P.o. BoX 4, jEffERson cIty, Mo 65102
statE of MIssoURI foR ovERnIgHt dELIvERIEs
dIvIsIon of PRofEssIonaL REgIstRatIon 3605 MIssoURI BLvd., jEffERson cIty, Mo 65109
tELEPHonE (573) 751-0098
statE BoaRd of REgIstRatIon foR tHE HEaLIng aRts toLL fREE (866) 289-5753
MALPRACTICE CLAIM INFORMATION faX (573) 751-3166

aPPLIcant Last naME fIRst naME MIddLE naME sUffIX datE

If you answered yes to question 14 on the application in section n, please answer the following questions for each claim. copy this page
as necessary.
PatIEnt naME PLaIntIff naME (If otHER tHan PatIEnt)

PatIEnt’s datE of BIRtH Last 4 of PatIEnt’s ssn

yoUR InvoLvEMEnt In tHE casE (attEndIng, consULtIng, Etc.) datE of occURREncE (MontH/day/yEaR)

statUs of tHE actIon (PEndIng, dIsMIssEd, sEttLEd, jUdgMEnt, dRoPPEd) MonEy PaId

dId tHE PatIEnt dIE?

yEs      no

If tHE casE Is cLosEd, PLEasE IndIcatE tHE MEtHod of REsoLUtIon.

dismissed with Payment - date: ________________ dismissed without Payment - date: ______________

settled, Payment Made - date: ________________ settled, no Payment Made - date: _______________

judgment in your favor - date: ________________ judgment against you - date: ___________________

other _______________________________________________ date: _____________

EXPLaIn tHE aLLEgatIon and PROVIDE A NARRATIVE SUMMARY REgaRdIng yoUR RoLE In tHE caRE PRovIdEd.
 STATE OF MISSOURI
DIVISION OF PROFESSIONAL REGISTRATION
STATE BOARD OF REGISTRATION FOR THE HEALING ARTS
3605 MISSOURI BLVD., P.O. BOX 4
JEFFERSON CITY, MO 65102 TELEPHONE (573) 751-0098
TOLL FREE (866) 289-5753

ARMED FORCES OF THE UNITED STATES

(1) Have you ever served on active duty in the Armed Forces of the United States and separated from such
service under conditions other than dishonorable? ___ Yes ___ No

(2) Are you the spouse of an active duty member of the Armed Forces of the United States? ___ Yes ___ No

If you answered questions (1) or (2) in the affirmative, please see the information below regarding the agency's
veteran services and return this form with verification of military status.

• Upon proof and approval, you may qualify for:

o Expedited Application Processing pursuant to section(s) 324.006 and 324.007, RSMo.
o Military Education, Training and Service Toward Licensure Qualification pursuant to section
324.007, RSMo.
o Licensure Reciprocity pursuant to section 324.009, RSMo.
o Fee Waiver Request pursuant to section 324.015, RSMo.

Veterans taking professional state licensing or certification examinations required by the Department of
Commerce & Insurance (DCI) can be reimbursed for the cost of the exam. Visit the Missouri Department of
Elementary and Secondary Education’s Veterans Education website to learn more about how the GI Bill can
pay the cost of a license or certification test.

Name (Please Print) Email Address

Address City State Zip Code