Form DH-MQA5002 "Osteopathic Physician Application for Temporary Certificate for Active Duty Military and Veterans Practicing in Areas of Critical Need" - Florida

What Is Form DH-MQA5002?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DH-MQA5002 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH-MQA5002 "Osteopathic Physician Application for Temporary Certificate for Active Duty Military and Veterans Practicing in Areas of Critical Need" - Florida

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Board of Osteopathic Medicine
P.O. Box 6330
Tallahassee, FL 32314-6330
Website: https://floridasosteopathicmedicine.gov /
Email: info@floridasosteopathicmedicine.gov
Phone: (850) 245-4161
Fax: (850) 412-2684
HEALTH
Quality
Medical
Assurance
Board of Osteopathic Medicine
P.O. Box 6330
Tallahassee, FL 32314-6330
Website: https://floridasosteopathicmedicine.gov /
Email: info@floridasosteopathicmedicine.gov
Phone: (850) 245-4161
Fax: (850) 412-2684
HEALTH
Quality
Medical
Assurance
Important Eligibility Information
This temporary and restricted licensure avenue is for osteopathic physicians who are on
active duty in the U.S. Armed Forces or served in the U.S. Armed Forces for at least ten
years and received an honorable discharge, and hold a current and valid license to
practice in any jurisdiction of the U.S. This license is restricted to practice in one of the
following:
an area of critical need;
a county health department;
a correctional facility;
a Department of Veterans’ Affairs clinic;
a community health center funded by section (s.) 329, s. 330 or s. 340 of the United
States Public Service Act;
another agency or institution approved by the State Surgeon General that provides
health care to meet the needs of underserved populations in this state; or
an area for a limited time to address critical physician-specialty, demographic or
geographic needs for Florida’s physician workforce as determined by the State
Surgeon General.
Florida Birth Related Neurological Injury Compensation Association (NICA) Fund
All physicians licensed in Florida are required to pay into the NICA fund unless qualified for exemption. Visit
https://www.nica.com/obgyns/index.html
for information on NICA participating, non-participating, and exempt.
“Participating,” is for Florida licensed physicians who practice obstetrics or perform obstetrical services on a full or part-
time basis and do not meet any of the exemption criteria.
“Non-participating,” is for Florida licensed physicians who do not practice obstetrics or perform obstetrical services and
do not meet any of the exemption criteria.
“Exempt,” to determine if you qualify for exemption review the exemptions listed below or visit the NICA website listed
above.
1. Resident physicians, assistant resident physicians and interns in postgraduate training programs approved by the
Board of Medicine (documentation of the dates of your program signed by the chair of your department must be
provided to NICA).
2. Retired physicians who maintain an active license, but who have withdrawn from employment in any medically
related field, as evidenced by an affidavit filed with NICA (a copy of this affidavit must be provided to the
Department of Health).
3. Physicians who hold a limited license, as defined by chapter (ch.) 458, Florida Statutes (F.S.), who do not receive
any
compensation for medical services (an affidavit must be provided to NICA stating that no compensation is
received for medical services).
4. Physicians employed full-time by the Veterans Administration whose practices are confined to Veterans
Administration hospitals (a letter from your employer stating you are a full-time employee as well as an affidavit
from you stating you are not engaged in the private practice of medicine must be provided to NICA).
5. Any licensed physician on active duty with the Armed Forces of the United States; (a letter from your commanding
officer stating that you are on active duty in the Armed Forces as well as an affidavit from you stating you are not
engaged in the private practice of medicine must be provided to NICA).
6. Physicians who are full-time state of Florida employees whose practice is confined to state owned correctional
facilities, mental health or developmental services facilities, or the Department of Health or County Health
Department (a letter from state government documenting your employment status as well as an affidavit from you
stating you are not engaged in outside employment must be provided to NICA).
DH‐MQA 5002, Revised 11/2020, Rule 64B15‐12.011, F.A.C.              
Page 2 of 24 
Osteopathic Physician Application for
Do Not Write in this Space 
For Revenue Receipting Only 
Temporary Certificate for Active Duty Military
and Veterans Practicing in Area of Critical Need
Board of Osteopathic Medicine
P.O. Box 6330
Tallahassee, FL 32314-6330
Fax: (850) 412-2684
Email: info@floridasosteopathicmedicine.gov 
All physicians licensed in Florida are required to pay into the NICA fund unless qualified for exemption. See page 2 for
information on NICA participating, non-participating, and exempt.
Osteopathic Physician Temporary Certificate (1905)
Fee includes the following:
Select the option applicable to your proposed practice setting
Initial Licensure Fee (refundable)
$429.00
Compensated Practice
$429.00 + NICA Fee
NICA Fee Varies Between
$0.00-$5,000.00
NICA Exempt: $0.00 - Total $429.00 (Submit proof of exemption)
Fees must be paid in the form of a cashier’s check
NICA Non-Participating: $250.00 - Total $679.00
or money order, made payable to the Department
NICA Participating: $5,000.00 - Total $5,429.00
of Health. Requests to withdraw or for a refund
must be made in writing. Fees are refundable for
Non-compensated Practice
No Fee
up to three years from the date of receipt.
(Submit affidavit regarding compensation from agency/institution)
1. PERSONAL INFORMATION
Name: ______________________________________________________________________ Date of Birth: _______________
Last/Surname
First
Middle
MM/DD/YYYY
Mailing Address: (The address where mail and your license should be sent)
___________________________________________________ _______ __________________________________
Street/P.O. Box
Apt. No.
City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Home/Cell Telephone (Input without dashes)
Approved Facility: (This address will be posted on the Department of Health’s website) Anticipated Start Date: _____________
MM/DD/YYYY
___________________________________________________ __________________________________________
Facility Name
Facility Director Name
___________________________________________________ _______ __________________________________
Street
(P.O. Box Addresses are not acceptable)
Suite No. City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Work/Cell Telephone (Input without dashes)
Type of Facility:
Community Health Center
Correctional Facility
County Health Dept
VA Clinic
Other:_______________________________________
EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-
Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is
gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
Gender:
Male
Race:
Native Hawaiian or Pacific Islander
Hispanic or Latino
White
Female
American Indian or Alaska Native
Black or African American
Asian
Two or More Races
Email Notification: To be notified of the status of your application by email, check the “Yes” box and fill in your email address on the
line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email
address with the board office.
Yes
No
Email Address: ____________________________________________________
2. SOCIAL SECURITY DISCLOSURE
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records
request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.
 
DH‐MQA 5002, Revised 11/2020, Rule 64B15‐12.011, F.A.C.  
Page 3 of 24 
2. SOCIAL SECURITY DISCLOSURE
This information is exempt from public records disclosure.
Pursuant to Title 42 United States Code
§ 666(a)(13), the department is required and authorized to
collect Social Security numbers relating to applications for professional licensure. Additionally, section
(s.) 456.013(1)(a), Florida Statutes (F.S.), authorizes the collection of Social Security numbers as part
of the general licensing provisions.
Last Name: _____________________________________________________________
First Name: _____________________________________________________________
Middle Name: ___________________________________________________________
Social Security Number: __________________________________________________
(Input without dashes)
Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is
voluntary unless specifically required by federal statute. In this instance, Social Security numbers are
mandatory pursuant to Title 42 United States Code
§
653 and 654; and s. 456.013(1), 409.2577, and
409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and
licensees by a Title IV-D child support agency to ensure compliance with child support obligations.
Social Security numbers must also be recorded on all professional and occupational license
applications and will be used for license identification pursuant to Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317). Clarification of
the SSA process may be reviewed at
www.ssa.gov
or by calling 1-800-772-1213.
DH‐MQA 5002, Revised 11/2020, Rule 64B15‐12.011, F.A.C.              
Page 4 of 24 
Name: _____________________________________________
3. APPLICANT BACKGROUND
A. List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.
___________________________________________________________________________________
B. List the year and state/territory/country you legally began to practice medicine. (This may be the date you began
postgraduate training.)
Year: ________
Location: __________________________
YYYY
State/Territory/Country
C. Has it been more than three years since you practiced osteopathic medicine in any jurisdiction?
Yes
No
If “Yes,” list the year you last practiced osteopathic medicine: ________
YYYY
D. Do you hold, or have you ever held a license to practice osteopathic medicine or any other professional
license(s)?
Yes
No
E. List all health-related licenses (active, inactive or lapsed).
Original Date
Expiration
License
State/Jurisdiction
License #
Issued
Date
Status of License
Type
or Country
(MM/DD/YYYY)
(MM/DD/YYYY)
Submit a “License Verification Request” form to ALL state(s) of licensure. License verifications must be
received directly from the licensing authority or
www.veridoc.org
regardless of the status of the license. Check
www.veridoc.org
for states that use the online verification service.
F. Are you registered with the Drug Enforcement Agency (DEA) to prescribe controlled substances?
Yes
No
G. If you have ever served in the United States (U.S.) Military or Public Health Service (PHS), have you ever been
disciplined by any branch of the U.S. Military or PHS?
Yes
No
NA
If “Yes,” provide the following:
A self-explanation on a separate sheet providing accurate details (including, but not limited to, the
date(s), location(s), and specific circumstances).
Documentation from the U.S. Military/PHS regarding the charge(s)/event(s).
4. DISASTER
Would you be willing to provide health services in special needs shelters or to help staff disaster medical
assistance teams during times of emergency or major disaster?
Yes
No
DH‐MQA 5002, Revised 11/2020, Rule 64B15‐12.011, F.A.C.  
Page 5 of 24