ࡱ> qsnopue dbjbj !cbcb|~UUcccccT6d6d6ddf46dNj ssstZw;d3555555$RYecY&c&cstiii^&cs(ct3i3iiFRc61s,57]ETԽ0! 11c(M|iɉd-YY-<UB a: LOUISIANA STATE BOARD OF MEDICAL EXAMINERS Renewals: 504/568-6820 (Auto Attendant) + 1 Main Number: 504/568-6820  Physicians (MD/DO) & Acupuncturists Application/Renewal Packet (Rev. 10 20 2020) Visit the LSBME Website at  HYPERLINK "http://www.lsbme.la.gov" www.lsbme.la.gov Louisiana State Board of Medical Examiners-New Orleans, Louisiana Physical & Application Processing Address: LSBME, 630 Camp Street, New Orleans, LA 70130  SPECIALTY CODE DESCRIPTIONS ADL Adolescent Medicine AM Aerospace Medicine A Allergy AI Allergy and Immunology AN Anesthesiology BE Broncho-Esophagology BLB Blood Banking CD Cardiovascular Diseases CCM Critical Care Medicine D Dermatology DMP Dermatopathology DIA Diabetics EM Emergency Medicine END Endocrinology REN Endocrinology, Reproductive FP Family Practice GE Gastroenterology GP General Practice GPM General Preventive Medicine GER Geriatrics GO Gynecological Oncology GYN Gynecology HEM Hematology HYP Hypnosis IG Immunology DLI Immunology, Diagnostic Lab IP Immunopathology ID Infectious Diseases IM Internal Medicine LAE Laryngology LM Legal Medicine MFM Maternal and Fetal Medicine MFS Maxillofacial Surgery MM Medical Microbiology NPM Neonatal-Perinatal Medicine ND Neoplastic Diseases NEP Nephrology N Neurology CHN Neurology, Child NA Neuropathology NM Nuclear Medicine NR Nuclear Radiology NTR Nutrition OBS Obstetrics OBG Obstetrics-Gynecology OM Occupational Medicine ON Oncology RO Oncology, Radiation OPH Ophthalmology OT Otology OTO Otorhinolaryngology PTH Pathology ATP Pathology, Anatomic CMP Pathology, Chemical CLP Pathology, Clinical FOP Pathology, Forensic PD Pediatrics PDA Pediatrics, Allergy PDC Pediatrics, Cardiology PDE Pediatrics, Endocrinology PHO Pediatrics, Hematology-Oncology PNP Pediatrics, Nephrology PDP Pediatrics, Pulmonology PA Pharmacology PM Physical Medicine and Rehabilitation P Psychiatry CHP Psychiatry, Child PYA Psychoanalysis PYM Psychosomatic Medicine PH Public Health PUD Pulmonary Diseases R Radiology RIP Radioisotopic Pathology DR Radiology, Diagnostic PDR Radiology, Pediatric TR Radiology, Therapeutic RHU Rheumatology RHI Rhinology AS Surgery, Abdominal CDS Surgery, Cardiovascular CRS Surgery, Colon and Rectal FPS Surgery, Facial Plastic, Oto. GS Surgery, General HS Surgery, Hand HNS Surgery, Head and Neck NS Surgery, Neurological ORS Surgery, Orthopedic PDS Surgery, Pediatric PS Surgery, Plastic TS Surgery, Thoracic TRS Surgery, Traumatic U Surgery, Urological VS Surgery, Vascular OS Other US Unspecified LSBME Renewal Fees *Foreign checks will NOT be accepted. Medicine & Surgery/DO/INST due on or before the last day of licensees birth month.MD/DOScheduled Renewal Fee $332.00After Last Day of Your Birth Month $632.00IF REDUCED FEEScheduled Renewal Fee $150.00After Last Day of Your Birth Month $300.00 Acupuncturists Due Date December 31.ACUScheduled Renewal Fee $100.00 Louisiana Department of Health and Hospitals Office of Public Health  September 2014 Dear Colleague: We would like to remind you about the importance of reporting communicable diseases. In light of recent events, the importance of enhancing surveillance for infectious disease and illnesses compatible with biological/chemical events cannot be overstated. The list of reportable diseases and conditions is currently being amended to include selected biological agents that might be used in a terrorist event (see attached). In Louisiana, disease surveillance rests on reporting to the Office of Public Health (OPH). All health care providers, including physicians, hospitals, and laboratories are required by law to report. The confidentiality of reports is protected by state law. The reports are used in several ways: The surveillance data are used by OPH and various other health care providers for health planning, policy making, and research. Individual case reports of certain diseases such as tuberculosis and syphilis receive follow-up by OPH to ensure that patients receive appropriate medical treatment and that their contacts receive appropriate preventive therapy. Reports of some infectious diseases such as measles, salmonellosis, and vibrio infections can lead to identification of disease outbreaks that can then be controlled. Reports also can be used to identify groups at high risk, prompting intervention efforts targeted at those groups. Summaries of surveillance data are presented in our bimonthly newsletter, The Louisiana Morbidity Report,  HYPERLINK "http://new.dhh.louisiana.gov/index.cfm/newsroom/archives/126" http://new.dhh.louisiana.gov/index.cfm/newsroom/archives/126, and in our Annual Summary Reports,  HYPERLINK "http://new.dhh.louisiana.gov/index.cfm/page/536" http://new.dhh.louisiana.gov/index.cfm/page/536. Rapid notification of potential bioterrorist events. For easier reporting, we have installed a toll-free number for reporting diseases (1 800-256-2748). You can report by phone, or by facsimile transmission (504-568-8290). For forms and guidelines please see  HYPERLINK "http://new.dhh.louisiana.gov/index.cfm/page/1013" http://new.dhh.louisiana.gov/index.cfm/page/1013. All facsimile transmissions are considered as part of the confidential disease case report, and as such, are not subject to disclosure. A website for the Infectious Disease Epidemiology Section, has been developed,  HYPERLINK "http://new.dhh.louisiana.gov/index.cfm/page/299" http://new.dhh.louisiana.gov/index.cfm/page/299 which includes disease and reporting information. Thank you for your interest in the health of Louisianas citizens. Sincerely,  Raoult Ratard, MD, MPH&TM, MS State Epidemiologist Sanitary Code - State of Louisiana Part II - The Control of Disease LAC 51:II.105: The following diseases/conditions are hereby declared reportable with reporting requirements by Class: Class A Diseases/Conditions - Reporting Required Within 24 Hours Diseases of major public health concern because of the severity of disease and potential for epidemic spread-report by telephone immediately upon recognition that a case, a suspected case, or a positive laboratory result is known; [in addition, all cases of rare or exotic communicable diseases, unexplained death, unusual cluster of disease and all outbreaks shall be reported. Acute Flaccid Paralysis Fish/Shellfish Poisoning (Domoic Acid, neuro- Plague (Yersinia pestis) Smallpox Anthrax toxic, Cigueatera, paralytic, Scombroid)Poliomyelitis (paralytic & non-paralytic)Staphylococcus aureus, Vancomycin Inter-Avian or novel strain Influenza A (initial Foodborne Infection Q Fever (Coxiella burnetii)  mediate or Resistant (VISA/VRSA)  detection) Haemophilus influenzae (invasive disease) Rabies (animal and human) Staphylococcal Enterotoxin B (SEB)BotulismInfluenza-associated Mortality Ricin Poisoning Pulmonary PoisoningBrucellosisMeasles (Rubeola imported or indigenous) Rubella (congenital syndrome) Tularemia (Francisella tularensis)CholeraNeisseria meningitidis (invasive infection) Rubella (German Measles) Viral Hemorrhagic FeverClostridium perfringens (foodborne infection) Outbreaks of Any Infectious Disease Severe Acute Respiratory Syndrome-associa- Yellow Fever Diphtheria Pertussis  ted Coronavirus (SARS-CoV)  Class B Diseases/Conditions - Reporting Required Within 1 Business Day Diseases of public health concern needing timely response because of potential of epidemic spread-report by the end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known. Amoeba (free living infection: Acanth- ChancroidHepatitis B (acute illness and carriage in Malaria amoeba, Naegleria, Balamuthia, others) Dengue Fever pregnancy)MumpsAnaplasmosisEscherichia coli, Shig-toxin producing Hepatitis B (perinatal infection) SalmonellosisArthropod-Borne Neuroinvasive Disease  (STEC), including E. coli 0157:H7 Hepatitis E Shigellosis (West Nile, St, Louis, California, Eastern Granuloma Inguinale Herpes (neonatal) Syphilis Equine, Western Equine, others) Hantavirus (infection or Pulmonary Syndrome) Human Immunodeficiency Virus2 [(HIV), Tetanus Aseptic Meningitis Hemolytic-Uremic Syndrome  infection in pregnancy] Tuberculosis3 (M. tuberculosis, M. bovis, BabesiosisHepatitis A (acute disease) HIV2 perinatal exposure]  M. africanum)Chagas Disease Legionellosis (acute disease) Typhoid Fever Class C Diseases/Conditions - Reporting Required Within 5 Business Days Diseases of significant public health concern-report by the end of the workweek after the existence of a case, suspected case, or a positive laboratory result is known. Acquired Immune Deficiency Syndrome3 GiardiaListeria Streptococcal Disease, Group A (AIDS) Glanders Lyme Disease  (invasive disease)Anaplasma Phagocytophilum Gonorrhea (genital, oral, ophthalmic, pelvic Lymphogranuloma Venereum1 Streptococcal Disease, Group BBlastomycosis inflammatory disease, rectal) Meliodosis (Burkholderia pseudomallei)  (invasive disease)Campylobacteriosis Hansens Disease (leprosy) Meningitis, Eosinophilic Streptococcal Toxic Shock SyndromeChlamydial infection Hepatitis B (carriage, other than in pregnancy) Nipah Virus Infection Streptococcus pneumoniae, invasive diseaseCoccidioidomycosisHepatitis C (acute illness) PsittacosisTransmissible Spongiform EncephalopathiesCryptococcosis Hepatitis C (past or present infection) Spotted Fevers [Rickettsia species including  (Creutzfeldt-Jacob Disease & variants)CryptosporidiosisHuman Immunodeficiency Virus2 (HIV  Rocky Mountain Spotted Fever (RMSF)] TrichinosisCyclosporiasis  (infection other than as in Class B) Staphylococcus aureus (MRSA) Varicella (chickenpox)Ehrlichiosis (human granulocytic and mono- Human T Lymphocyte Virus (HTLV I and II  invasive infection Vibrio Infections (other than cholera)  cytic, Ehrlichia chaffeensis)  infection) Staphylococcal Toxic Shock SyndromeYersiniosisEnterococcus, Vancomycin Resistant [(VRE) Leptospiriosis  invasive disease]  Class D Diseases/Conditions - Reporting Required Within 5 Business Days CancerHeavy Metal (Arsenic, Cadmium, Mercury) Pesticide-Related Illness or Injury (all ages)5Severe Undernutrition (severe anemia,Carbon Monoxide Exposure and/or Poisoning5 Exposure and/or Poisoning (all ages)5Phenylketonuria4 failure to thrive) Complications of AbortionHemophilia4Reyes SyndromeSickle Cell Disease4 (newborns) Congenital Hypothyroidism4Lead Exposure and/or Poisoning Severe Traumatic Head InjurySpinal Cord Injury Galactosemia4 (children)4, (adults)5 Sudden Infant Death Syndrome (SIDS) Case reports not requiring special reporting instructions (see below) can be reported by mail or facsimile on Confidential Disease Report forms (2430), fascimile (504) 568-8290, telephone (504) 568-8313, or 1-800-256-2748 for forms and instructions. Report on STD-43 form. Report cases of syphilis with active lesions by telephone, within one business day, to (504) 568-8374. Report to the Louisiana HIV/AIDS Program: Visit  HYPERLINK "http://www.hiv.dhh.louisiana.gov" www.hiv.dhh.louisiana.gov or call 504-568-7474 for regional contact information. 3Report on CDC72.5 (f.5.2431) card 4Report to the Louisiana Genetic Diseases Program and Louisiana Childhood Lead Poisoning Prevention Programs:  HYPERLINK "http://www.genetics.dhh.louisiana.gov" www.genetics.dhh.louisiana.gov or call (504) 568-8254. 5Report to the Section of Environmental Epidemiology and Toxicology:  HYPERLINK "http://www.seet.dhh.louisiana.gov" www.seet.dhh.louisiana.gov or call 1-888-293-7020 LOUISIANA STATE BOARD OF MEDICAL EXAMINERS LSBME, 630 Camp Street, New Orleans, LA 70130 (504) 568-6820 (Auto Attendant) + 1 MD/DO/ACU APPLICATION FOR LICENSE/CERTIFICATE RENEWAL (Please allow 30 days for processing) Complete this form PRIOR to printing. It contains form fields to make it user friendly. Have you ever applied for a physicians license in Louisiana prior to now?  FORMCHECKBOX Yes  FORMCHECKBOX No Have you ever been licensed as a physician in Louisiana?  FORMCHECKBOX Yes  FORMCHECKBOX No Amount Due:  FORMTEXT      *Foreign checks will NOT be accepted.. Due Date:  FORMTEXT       Name and Mailing Address:  FORMTEXT      License #:  FORMTEXT       Credential Type:  FORMTEXT       Credential Status:  FORMTEXT       INSTRUCTIONS: RENEWAL IS REQUIRED BY LAW ON OR BEFORE THE DUE DATE ABOVE. FAILURE TO RENEW TIMELY MAY RESULT IN SUSPENSION FOR NON-RENEWAL. SEE SPECIAL INSTRUCTIONS FOR FORMS AND FEES. ADDRESSES: Must provide at least 1 physical address. Check to specify one Public and one Mailing address. *Public Address: Address that is posted on the LSBME Website. *Mailing Address: Mailings from the LSBME will go to this address. BUSINESS ADDRESS  FORMCHECKBOX Public Address  FORMCHECKBOX Mailing Address  FORMTEXT      PHONE:  FORMTEXT       FAX:  FORMTEXT       E-MAIL:  FORMTEXT      HOME ADDRESS  FORMCHECKBOX Public Address  FORMCHECKBOX Mailing Address  FORMTEXT      PHONE:  FORMTEXT       FAX:  FORMTEXT       E-MAIL:  FORMTEXT      OTHER ADDRESS  FORMCHECKBOX Public Address  FORMCHECKBOX Mailing Address (i.e., P.O. Boxes, Alt. Business Address, etc)  FORMTEXT       PHONE:  FORMTEXT       FAX:  FORMTEXT       E-MAIL:  FORMTEXT       Are you a U.S. Citizen? FORMCHECKBOX  YES  Answer below FORMCHECKBOX  NO  Answer below  FORMCHECKBOX Born in the U.S. (OR)  FORMCHECKBOX Naturalized - Must provide a current copy of your paperwork. DO YOU CURRENTLY HOLD:  FORMCHECKBOX J1 Visa - A copy of your DS-2019 will be required to renew your license.  FORMCHECKBOX H1B Visa A copy of your I-94 form & a current passport will be required to renew your license.  FORMCHECKBOX Permanent Resident Card A current copy will be required to renew your license.  FORMCHECKBOX Employment Authorization Card A copy of this card & a current passport will be required to renew your license.  FORMCHECKBOX OTHER Must provide a copy of your current citizenship document. Controlled Substances Permit # s DEA #:  FORMTEXT       Exp. Date:  FORMTEXT       Louisiana State CDS #:  FORMTEXT       SPECIALTIES: See  Code Descriptions Specialty (1)  FORMTEXT       (2)  FORMTEXT       (3)  FORMTEXT       (4)  FORMTEXT       Certification Year (1)  FORMTEXT       (2)  FORMTEXT       (3)  FORMTEXT       (4)  FORMTEXT       CHECK APPLICABLE BOX If partnership, corporation or institutional, provide name of legal entity. FORMCHECKBOX  SOLO FORMCHECKBOX  GROUP FORMCHECKBOX  MILITARY FORMCHECKBOX  RESIDENT TRAINING FORMCHECKBOX  PARTNERSHIP  FORMTEXT       FORMCHECKBOX  INSTITUTIONAL  FORMTEXT       FORMCHECKBOX  CORPORATION  FORMTEXT       FORMCHECKBOX  OTHER  FORMTEXT       LOUISIANA STATE BOARD OF MEDICAL EXAMINERS 630 Camp Street, New Orleans, LA 70130 PHYSICIANS WHO EMPLOY PRIVATE RADIOLOGICAL TECHNOLOGISTS You must complete this form for each Private Radiological Technologist that you employ.RETURN IN THE SAME ENVELOPE WITH ANNUAL RENEWAL FORM AND APPLICATION FEE LAC 46 XLV Subpart 2, Chapter 29, Subchapter B, Sec. 2917 of the Louisiana State Board of Medical Examiners rules governing the certification of Private Radiological Technologists requires that each physician who employs any person to perform diagnostic or therapeutic radiological examinations or treatments or both in his private office or in the clinic in which that physician practices shall report to the Board annually as a condition of issuance or renewal of that physicians licensure to practice medicine in the state of Louisiana the following information for each person so employed. This form may be copied. PRIVATE RADIOLOGICAL TECHNOLOGIST Employee Name:  FORMTEXT       License Number:  FORMTEXT       Certification Number*:  FORMTEXT       Address at which diagnostic or therapeutic radiological examinations and/or treatments are performed:  FORMTEXT       Initial date of employment as a Private Radiological Technologist:  FORMTEXT       Exemption(s) Claimed: 1.  FORMCHECKBOX  a. Physician licensed by the board to practice medicine in the State of Louisiana; or b. Person licensed by the Radiologic Technology Board of Examiners. 2.  FORMCHECKBOX  Person who performs the functions of a private radiologic technologist, but has been employed by the supervising physicians for less than six months shall be exempt from the requirements of Chapter 29 only for the first six months of such employment. NOTE: This temporary exemption shall not apply to anyone who has been employed previously as a private radiologic technologist or who has otherwise performed any radiological examination or treatment in the course of any previous employment. CERTIFICATION BY PHYSICIAN I hereby certify that this individual is proficient in, and is competent to perform the functions of a private radiologic technologist. Date  FORMTEXT       Print Name:  FORMTEXT       License No.:  FORMTEXT       Signature: _______________________________________ *Only those individuals who have applied for certification have a certification number. Note: Those individuals who are licensed by the Radiologic Technology Board of Examiners are exempt from the requirement of obtaining certification from the Louisiana Board of Medical Examiners. CME CERTIFICATION Every physician seeking the renewal or reinstatement of licensure is required to obtain annually 20 hours of Category 1 credit unless exempted. Physicians falling within any of the following categories are exempt: Initially licensed less than 1 year on the basis of examination; Engaged in military service longer than one years duration outside of Louisiana; Certified or recertified within the past year by a member board of the American Board of Medical Specialties; Currently in a residency training or fellowship approved by the Board; Retired physician in accordance with 418 of the rules. As part of such CME requirement, physicians seeking to renew their license for the FIRST time must have attended a Board sponsored Orientation. (You can register  HYPERLINK "http://www.lsbme.la.gov/licensure/physicians/board-orientation" here.) Physicians who at the time of the initial renewal of medical licensure are residing and practicing in another state are exempt from attending the Board Orientation. However, in the event that the physician should return to Louisiana for the purpose of residing or practicing medicine, he must satisfy this requirement prior to the next renewal. My signature certifies my understanding of the CME requirements for continued renewal of my license to practice medicine in Louisiana. Signature: __________________________________________________________ MD/DO ONLY Complete this section Collaborative Drug Therapy Management Do you currently hold a CDTM permit?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, check this box  FORMCHECKBOX  to verify that your practice guidelines have not changed. OFFICE BASED SURGERY (OBS)  Do you perform surgical procedures in your office that require the administration of drugs that induce alteration of consciousness?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, Is your facility accredited by any of the following organizations? DHH  FORMCHECKBOX Yes  FORMCHECKBOX No JCAHO  FORMCHECKBOX Yes  FORMCHECKBOX No AAAASF  FORMCHECKBOX Yes  FORMCHECKBOX No AAAH  FORMCHECKBOX Yes  FORMCHECKBOX No What is the address of the facility you perform OBS?  FORMTEXT       Name(s) and license numbers of qualified monitoring personnel:  FORMTEXT       List type of procedures performed:  FORMTEXT       TELEMEDICINE - The practice of health care delivery, diagnosis, consultation, treatment, and transfer of medical data by a physician using interactive telecommunication technology that enables a physician and a patient located in this state separated by distance to interact via audio and/or video simultaneously. This does not apply to intraoperative monitoring, pathology or radiology. Is Telemedicine utilized in your practice?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, Provide a brief description?  FORMTEXT       Are you associated or affiliated with a telemedicine company?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, Provide the name of the company:  FORMTEXT       Does your telemedicine practice treat patients in Louisiana:  FORMCHECKBOX Yes  FORMCHECKBOX No If yes,  FORMCHECKBOX Individual Basis  FORMCHECKBOX Hospital or Clinic - Name of Hospital or Clinic  FORMTEXT       COLLABORATING PRACTICES: Do you have a collaborating practice agreement with an APRN?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, complete below.Practitioner NameSpecialtyAddress of primary practice location of APRN FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Controlled Dangerous Substance - Continuing Medical Education As per legislation passed in 2017, all practitioners with a Controlled Dangerous Substance (CDS) license in Louisiana are now required to complete at least 3 hours of Board approved continuing medical education (CME) that includes ALL 4 of the below topics. This course is a once in a lifetime requirement under current law. This 3 hour requirement will be considered a part of, and not in addition to, the prescribers annual CME requirement. By checking the boxes below I certify that I have completed at least 3 hours of Board Approved CME covering the topics below. The course(s) MUST be on the approved course list or it will not be accepted. To see the list of approved courses go to  HYPERLINK "http://www.lsbme.la.gov" www.lsbme.la.gov. Click on Orientations & Education, then click on *NEW HYPERLINK "http://www.lsbme.la.gov/content/board-approved-cme-courses-cds-requirements"  Board Approved CME Courses for CDS Requirements.  FORMCHECKBOX Best Practices  FORMCHECKBOX Chronic Pain  FORMCHECKBOX Diversion  FORMCHECKBOX Addiction Tx *You must attach copies of your certificates of completion to this renewal. If you have already submitted your certificate(s) of completion and they were approved, check the box below:  FORMCHECKBOX Certificate(s) of completion previously submitted & approved *Exemption Requests* An authorized prescriber renewing his/her license for the first time may be excused from the CME requirement upon submission of a certification attesting that he/she has not prescribed, administered or dispensed any CDS in Louisiana during the entire year covered by the prescribers expiring license. The Board will verify the certification through the Louisiana Prescription Monitoring Program. An exempted licensee, who subsequently prescribes, administers or dispenses a CDS shall satisfy the CME requirement as a condition to license renewal for the year immediately following that in which the CDS was prescribed, administered or dispensed.  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affidavit -AFFIDAVIT MUST BE TYPED & NOTARIZED!) YesNo1SINCE YOUR LAST RENEWAL - Have you had any physical injury or disease or mental illness or impairment, which could reasonably be expected to affect your ability to practice medicine or other health profession? You may answer no to this question if you are currently in the Physicians' Health Foundation of Louisiana and in good standing. FORMCHECKBOX  FORMCHECKBOX 2SINCE YOUR LAST RENEWAL - Have you been referred to or obtained treatment for a substance abuse disorder including alcohol abuse? You may answer no to this question if you are currently in the Physicians' Health Foundation of Louisiana and in good standing. FORMCHECKBOX  FORMCHECKBOX 3SINCE YOUR LAST RENEWAL - Have you been cited, arrested, charged with, convicted of or pled guilty or nolo contendere to a violation of any municipal, state or federal statute including any that have been expunged or judicially removed for any reason with the exception of misdemeanor traffic offenses or traffic ordinance violations that do NOT involve the use of drugs or alcohol? FORMCHECKBOX  FORMCHECKBOX 4SINCE YOUR LAST RENEWAL - Has your application for any professional license, certificate, or registration been denied by any state licensing board or federal authority? FORMCHECKBOX  FORMCHECKBOX 5SINCE YOUR LAST RENEWAL - Has your professional license, certificate, or registration been the subject of investigation or revoked, suspended, probated, restricted, reprimanded, limited, or subjected to any other disciplinary action by any state licensing board or federal authority? FORMCHECKBOX  FORMCHECKBOX 6SINCE YOUR LAST RENEWAL - Have you voluntarily surrendered any professional license, or agree with any licensing authority not to seek re-licensure in order to avoid disciplinary action, investigation or inquiry? FORMCHECKBOX  FORMCHECKBOX 7SINCE YOUR LAST RENEWAL - Was your application for staff or clinical privileges at any hospital, clinic, or other health care institution denied?  FORMCHECKBOX  FORMCHECKBOX 8SINCE YOUR LAST RENEWAL - Were you the subject of an inquiry or investigation by any hospital, clinic, or other health care institution which resulted in the suspension, restriction, probation or other limitation on your affiliation or staff or clinical privileges; including remediation and/or non-disciplinary sanctions? FORMCHECKBOX  FORMCHECKBOX 9SINCE YOUR LAST RENEWAL - Did you surrender or fail to renew staff or clinical privileges at any hospital, clinic, or other health care entity in lieu of investigation, while under investigation or while you were the subject of disciplinary proceedings?  FORMCHECKBOX  FORMCHECKBOX 10SINCE YOUR LAST RENEWAL - Were you the subject of disciplinary action, placed on academic probation, or asked to undergo additional training or remediation during your professional training (as a student, intern, resident, fellow, or other trainee)? FORMCHECKBOX  FORMCHECKBOX 11SINCE YOUR LAST RENEWAL - Has your participation in any private, federal or state health insurance program been terminated, non-renewed, denied, suspended, restricted, placed on probation, or are you the subject of a current investigation or proceeding by such entities? FORMCHECKBOX  FORMCHECKBOX 12SINCE YOUR LAST RENEWAL - Have you surrendered your state or federal controlled substances permit or registration? FORMCHECKBOX  FORMCHECKBOX 13SINCE YOUR LAST RENEWAL - Has your membership in a professional society been revoked, suspended, or disciplined or have you resigned membership while under investigation  FORMCHECKBOX  FORMCHECKBOX 14SINCE YOUR LAST RENEWAL - Were any malpractice claims settled by you or on your behalf? FORMCHECKBOX  FORMCHECKBOX 15SINCE YOUR LAST RENEWAL - Has any court determined you are currently in violation of a courts judgment or order for the support of dependent children?  FORMCHECKBOX  FORMCHECKBOX  I hereby certify that to the best of my knowledge, all statements I have made in this application for renewal are true and correct. Signed (no stamps) ____________________________________ Date________________________________  Fees are not prorated (i.e. License received mid-year fee payable in full, next annual renewal payable in full)  See Application for Reduction in Renewal Fee for Physicians. LAC 46:XLV, Subpart 2, Chapter 3, Subchapter I, 418. 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