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Middlesex Massachusetts online Form 1041: What You Should Know

Department of Public Health for an individual and 1429 with the board of the Department of Motor Vehicles for an individual for the duration of the physician's license for purposes of licensure. The physician shall notify the State Board of Registration of Private Occupational Licenses within 5 days of his request for the expedited license. The board shall approve the application if the board determines that the individual is competent to practice his profession. The application shall provide: (1) the name, Social Security Number, residency and physical address and date of birth of the applicant, if different; (2) proof of professional qualification; and (3) an application fee of 40.00. If the applicant is a Massachusetts resident, the application shall also require registration in the Statewide Medical License Tracking System (SALTS) by the applicant. Individuals licensed under this section that are not eligible under section 1(a)(1)(I) of chapter 119 shall file an application with a designated agent of the licensed physician. Such agent shall certify the information on the application submitted to the Division within 5 days of receipt. The physician shall immediately file the application, providing proof of qualification. Within 30 days of receipt of the application, the Division shall determine if the physician is qualified to practice his profession. At that time the physician shall file any additional information required by the Division and the board shall issue the license. If the physician fails to have the identification document and identification card when they are required by law, and fails to certify to the Division by the time the physician submits his application that the physician is competent to practice his profession, the doctor shall be disqualified from registration as a physician and shall not be eligible or able to issue any license. The Division shall immediately deny the application of the physician unless the physician provides the following: (1) an affidavit or declaration under oath that he has never been convicted of one of the enumerated crimes under section 8(1)(A)(ii); (2) a copy of the applicant's most recent, unencumbered driver's license issued by another state; and (3) proof from the licensed physician of the physician's financial capacity as to the time for which he is qualified to practice.  In the latter event, but excluding any criminal conviction that occurred within the last 2 years, the physician must file with the Division, within 30 days, a certified statement from the licensed physician which demonstrates he is financially capable to engage in health care practice.

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