Texas State Board of Medical Examiners - PDF

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					                                         Texas Medical Board
                             LOCAL ADDRESS: 333 GUADALUPE, TOWER 3, SUITE 610 • AUSTIN TX 78701
                                    MAILING ADDRESS: P.O. BOX 2029 • AUSTIN TX 78768-2029
                                                  WEB: www.tmb.state.tx.us




                     Surgical Assistant Licensure Application
                             (Forms A, B, C, D, E & F)
The medical board protects consumers through a comprehensive review of each applicant’s competency,
professional conduct, and physical and mental ability to safely engage in practice as a surgical assistant.

An applicant who provides false information or a false response to any of the questions is subject to
denial of licensure and being reported to the appropriate data banks.

The following information is provided to assist you in the application process:

 1. Complete all of the information on Forms A, B and C, as well as the top portions on Forms D, E and F of the
    Application for Surgical Assistant Licensure. Please type or print clearly.

  2. Submit the $305.00 licensure fee in the form of a personal check, cashier’s check or money order payable
     to the Texas State Board of Medical Examiners.

  3. Applications are reviewed in the order of receipt.

  4. All Forms (A, B, C, D, E and F) and supporting documentation (unless otherwise noted in the instructions)
     must be submitted to the board by the applicant in a single envelope. Applications that do not include
     all required information and forms will not be accepted for processing.

  5. If additional documentation is required from you, you will be notified.

  6. Please visit the board’s website at www.tmb.state.tx.us and review the board’s rules and policies. It is your
     responsibility to review the rules under Chapter 184, as well as Chapter 206 of the Occupations Code,
     before signing the Applicant’s Oath. These can be found under the Rules & Guidelines on the board’s
     website. Eligibility for licensure in Texas is set out in the board’s rules.

 7. Temporary licensure is available for applicants whose files have been determined to be complete. You
    will be advised of the Temporary License process when you are notified that your application is complete.
    The Temporary License will not have a number associated with it.

 8. The board awards licenses at its regularly scheduled meetings. Dates of the medical board meetings are
    located on the board’s website here . At the time that your application is determined to be complete, you
    will be informed of the dates of the board meeting at which your application will be considered. In most
    instances you will not be asked to attend the board meeting.

  9. Questions regarding licensure should be directed to Pre-Licensing, Registration & Consumer Services at
     1-512-305-7130 between the hours of 8 a.m. and 5 p.m. Central Time. Please visit the board’s website
     and review the board’s rules and policies prior to contacting the board.




TMBSURGICAL ASSISTANT LICENSURE APPLICATION                  1                                          SA 1/14/09
                                                             Instructions
                   For Completing Your Surgical Assistant Licensure Application Forms
The following information is provided in order to help you complete your licensure application forms. Please type
or print clearly in ink and provide full details for each question, including dates, complete names, addresses, and
zip codes when applicable.
                                                                  Form A
You must complete all information on this form and sign the oath before a Notary Public. In addition, submit the
following documentation to the board along with the other forms in a single envelope (unless otherwise noted).
Birth Certificate/Proof of Age: You must submit a copy of your birth certificate or a copy of your current
Driver’s License or passport.
Name Change Document: If any of your documents show a name other than the name on your application,
submit one of the following:
     •    Marriage - Furnish a copy of your marriage certificate.
     •    Divorce - Furnish a copy of your divorce decree.
     •    Adoption - Furnish a copy of your adoption order.
     •    Court Order - Furnish a copy of your name change document.
     •    Naturalization - You will be required to send your original naturalization certificate by certified mail to the board office for
          inspection. It is unlawful to copy this particular document.

Post-Secondary Education (Associate’s Degree): You must have been awarded at least an associate’s
degree at a two or four year institution of higher education. Request a certified transcript issued by the
college/university, which indicates the date the degree was awarded, be submitted directly to the board from
the college/university.
Educational Program: You must have a certified transcript of your educational program (surgical assistant
program, medical school, registered nurse first assistant program, or surgical physician assistant program)
submitted directly to the board from the program/school in a sealed envelope with the signature of an official of
the program/school over the sealed flap. A photocopy of your transcript will not be accepted unless it is sent
directly from your educational institution with proper certification.
===================================================
Board Rule 184.4.(a)(13)(C) The curriculum of an educational program listed in subparagraphs (A) and (B) of this paragraph must include
at a minimum, either as a part of that curriculum or as a required prerequisite, successful completion of college level instruction in the
following courses::
          (i)         anatomy;
          (ii)        physiology;
          (iii)       basic pharmacology;
          (iv)        aseptic techniques;
          (v)         operative procedures;
          (vi)        chemistry;
          (vii)       microbiology;
          (viii)      pathophysiology;

Examination Verification: You must have a letter submitted directly to the board from the appropriate testing
service verifying that you passed a surgical assistant examination, or it may be sent to the applicant in a sealed
envelope with the signature of an official of the testing service over the sealed flap. If it is sent to the applicant,
the applicant must submit it to TMB in the original sealed envelope along with all other forms in the original
sealed envelopes. To request your score report contact the following:
         ABSA         (American Board of Surgical Assistants)                                   www.absa.net
                               303-617-8345           or   877-617-8345
         NBSTSA       (National Board of Surgical Technology and Surgical Assisting)             http://www.nbstsa.org/
                               800-707-0057
         NSAA         (National Surgical Assistant Association)        http://www.nsaa.net/index.htm
                      602-212-0479 or 888-633-0479
Board Certification: You must submit a copy of your valid and current certificate from the ABSA, NBSTSA,
or NSAA.
License Verification: You must request a letter of current status (licensure verification) be sent directly to the
board from all state/provincial licensing agencies through which you have ever been licensed, registered or
certified.




TMBSURGICAL ASSISTANT LICENSURE APPLICATION                              2                                                            SA 1/14/09
                                                    Form B
Submit a personal statement providing full details for each response that you have answered “Yes”. In addition,
contact all third parties involved or noted and have documentation submitted directly to the board’s offices.

Question 1. If you have ever been arrested have the arresting authority submit certified copies of the arrest
  record. If the arrest has been adjudicated have the court also send all records relevant to the arrest. All
  documentation relative to a conviction must be sent from the appropriate third party directly to the board’s
  offices.
Question 2. Have the jurisdiction that is the record holder submit all documentation relative to the action or
  complaint directly to the board.
Question 3. Have the entity that took action submit all documentation relating to the action directly to the
  board.
Question 4. Have all entities involved in any of these public or private actions submit directly to the board all
  records relative to the action.
Question 5. Have the appropriate entity submit a certified copy of your student, training, credentials and /or
  personnel file directly to the board.
Question 6. Have Form F completed by every malpractice carrier who has insured you. Once completed, the
  malpractice carrier should return the form to you so that you may submit it with your application. If the
  claim/action is currently pending, have the attorney representing you send a letter directly to the board
  stating the allegation and planned defense.
Question 7. Have each facility, individual, physician, psychologist, sponsor or other persons or entity that has
  been involved in the diagnosis or treatment of your disorder, condition or addiction submit documentation
  directly to the board. Documentation should include but is not limited to in-patient records, outpatient
  records, treatment records, letters of compliance, contracts, substance screening records, and AA/NA
  attendance records.
You must complete and sign the oath before a Notary Public.


                                      Form C - Work Experience
You must complete the information on this form to document completion of full-time work experience performed
in the United States under the direct supervision of a physician licensed in the United States and consisting of at
least 2,000 hours of performance as an assistant in surgical procedures for the three years preceding the
date of your application, or since your graduation from an educational program, whichever is the shorter
period, as required in accordance with Sec. 206.203.(b)(3) of the Occupations Code.
You must then have Form D completed by each physician that you listed on Form C, who can verify the majority
of hours that you worked as a surgical assistant under their direct supervision, for the preceding three years or
since your graduation from an educational program, whichever is the shorter period.
You must complete and sign the oath before a Notary Public.


                                          Form D - Verification
This form must be completed by each physician that you listed on Form C, who can verify the majority of hours
that you worked as a surgical assistant under their direct supervision, for the preceding three years or since
your graduation from an educational program, whichever is the shorter period.
You may make as many copies as needed. You must complete the information on the top of this form and then
request the supervising physician to complete the remaining portion of the form. Letters of recommendation are
not accepted in lieu of this form.

The supervising physician must have been licensed in the United States either as a doctor of medicine or doctor
of osteopathic medicine, during the time that you completed the hours. The supervising physician must also be
able to verify the hours that you worked as a surgical assistant under their direct supervision, for the preceding
three years or since your graduation from an educational program, whichever is the shorter period.



TMBSURGICAL ASSISTANT LICENSURE APPLICATION              3                                                SA 1/14/09
The supervising physician must complete and sign the oath before a Notary Public and then place this form in
an envelope of the institution/group that he/she represents, seal the envelope and place his/her signature over
the outside sealed envelope flap.

The supervising physician must return this form to you in the sealed envelope with his/her signature
over the outside sealed flap.


                                              Form E - Evaluation
You must provide evaluations of your professional affiliations for the past three years or since your graduation
from an educational program, whichever is the shorter period. The evaluations must be completed by at least
three physicians who have supervised you for: 1) more than 100 hours, or, 2) a majority of your work experience.

If you have not been supervised by at least three physicians, you will be required to furnish a personal statement
providing full details.

You may make as many copies as needed. You must complete the information on the top of this form and then
request the evaluating physician to complete the remaining portion of the form. Letters of recommendation are
not accepted in lieu of this form.

The evaluating physician must have been licensed in the United States either as a doctor of medicine or doctor
of osteopathic medicine, during the time period indicated on the form. The evaluating physician must also have
supervised you for the preceding three years or since your graduation from an educational program, whichever
is the shorter period, for: 1) more than 100 hours, or, 2) a majority of your work experience.

The evaluating physician must complete and sign the oath before a Notary Public and then place this form in an
envelope of the institution/group that he/she represents, seal the envelope and place his/her signature over the
outside sealed envelope flap.

The evaluating physician must return this form to you in the sealed envelope with his/her signature over
the outside sealed flap.


                                   Form F - Liability Claims Report
This form must be completed ONLY if you have ever been named in a claim or action as any health professional.
You may make as many copies as needed. You must complete the information on the top of this form and then
request your liability carrier to complete the remaining portion of the form.

The liability carrier must return this form to you in the sealed envelope with the signature of the person
completing the form over the outside sealed flap.

For each claim that has become a malpractice suit, have the attorney that represented you in each suit, submit a
letter directly to the board explaining:
                               1) the allegation,
                               2) relevant dates of the allegation, and
                               3) current status of the suit.

If the suit has been closed, the attorney must state:
                              1)   the disposition of the suit, and
                              2)   if any money was paid, the amount of the settlement.

If such letter is not available, you will be required to furnish a notarized statement explaining why this letter
cannot be provided.




TMBSURGICAL ASSISTANT LICENSURE APPLICATION                4                                                SA 1/14/09

				
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