Application For Renewal of Oklahoma License
Medical Doctor From 12/01/1999 To 11/30/2000
This form must be completed and returned to this office with a renewal fee of $200.00 on or before November 30, 1999. After that date, the license becomes inactive. Renewals may be accepted for 60 days with a fee of $350.00. After 60 days, unrenewed Licensees are suspended. You cannot practice with an inactive or suspended license.
 
Mail Renewal application to: Oklahoma State Board of Medical Licensure and Supervision
101 NE 51st St
Oklahoma City, OK  73105-1821
Email this form to: licensing@okmedicalboard.org
 
License Number:   
Mailing Address Practice Address

,
Not currently practicing
    Yes No
You are required pursuant to 59 O.S. 355 1(B) to indicate your preference. Please read and check in the appropriate response. Any Medical Doctor who desires to DISPENSE "dangerous drugs" as defined in the Pharmacy Law, must register annually with the Board. This is for dispensing only and does not include prescribing, administering, or the giving of samples.
    
I wish to be registered to dispense dangerous drugs.   X
The following information is mandatory and information provided may be investigated further.
Since do any of the following apply to you?
  
A. Since last renewal, have you ever been denied provider participation, terminated, sanctioned, or penalized by any third-party payor, to include TRICARE, MEDICARE, MEDICAID?   X
B. Since last renewal, have you ever surrendered or had any adverse action taken against any narcotic permit (state or federal)?   X
C. Since last renewal, have you ever been denied membership or had disciplinary action taken by a national, state or county professional organization?   X
D. Since last renewal, have you ever been denied or had removed or suspended hospital staff privileges?   X
E. Since last renewal have you ever surrendered hospital staff privileges while under investigation or to avoid investigation?   X
F.Since last renewal, have you ever entered into an agreement with a federal, state, or local jurisdictional body to avoid formal action?   X
G.Since last renewal, have you been the subject of an investigation, probation, or disciplinary action by a hospital, clinic, practice group, or training program?   X
H.Since last renewal, have you had any adverse judgment, settlement, or award against you arising from a professional liability claim?   X
I.Since last renewal, have you had professional liability coverage declined, canceled, issued on special terms or renewal refused?   X
J.Since last renewal, have you been reported to the National Practitioner Data Bank (NPDB)?   X
K.Since last renewal, has your application for a professional license been denied?   X
L.Since last renewal, have you surrendered a license or had a license revoked?   X
M.Since last renewal, has any disciplinary action been taken on any license?   X
N.Since last renewal, have you been subject of a review by professional licensing/regulatory agency, other than the Oklahoma State Board, based on a complaint filed against you?   X
O.Since last renewal, have you ever been arrested for or convicted of a felony or misdemeanor, or are charges currently pending against you?   X
  DO YOU WISH TO APPLY FOR PHYSICIAN EMERITUS (FULLY RETIRED) STATUS?   X
The Following Restrictions apply to Physician Emeritus (FULLY RETIRED) Physicians:
   A) You may continue to use the title "DOCTOR" and suffix "MD", but must indicate retired status.
   B) You cannot practice medicine in any form. You cannot prescribe, dispense or administer drugs.
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Specialties:
     No Specialties Listed
Board Certifications (Current):
     No Certifications Listed
Post Graduate Training (Current):
Type of Training:  
Hospital:  
Location:  
Date Entered:  
Expected Completion Date:  
Practice Information (Current):
Employer:  
City, State, County:  
Type of Practice or Specialty:  
Date Started:  
I, the undersigned, have to the best of my knowledge, complied with the laws and rules regulating my profession. I hereby state that the information contained in this application is true and correct. This form is public information.
Signature of Applicant:   Date:  
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Application For Renewal of Oklahoma License
Medical Doctor From 12/01/1999 To 11/30/2000
License Number:    05/04/2025 06:11:53am
THIS INFORMATION IS PRIVILEGED, CONFIDENTIAL, NOT SUBJECT TO DISCOVERY AND EXEMPT FROM PUBLIC DISCLOSURE
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
43A Ok. Stat. §1-109

MENTAL AND PHYSICAL HEALTH QUESTIONARE:
Oklahoma Health Professionals Program (OHPP)
The Board recognizes that licensees may suffer from potentially impairing health concerns, including psychiatric illnesses and physical illnesses which may impact cognition, as well as substance use disorders. The Board expects its licensees to properly address their health concerns to ensure patient safety. The failure of a licensee to adequately address any health condition which may impair their ability to practice medicine with reasonable skill and safety will likely result in the Board taking action against the licensee.

The Board encourages licensees to utilize the services of the OHPP. OHPP is a confidential resource which provides advocacy for licensees and promotes wellness. OHPP does not itself treat those who participate but facilitates a participant’s treatment and provides monitoring as needed. Examples of conditions that OHPP can monitor include substance abuse and addiction issues, mental health issues, and other related conditions that may interrupt a licensee’s practice.

You may contact OHPP for further information by calling 405-601-2536 or via email at ohpp@okmed.org. Downloadable self-report forms can be found on the OHPP website, okhpp.org, under the “Forms” section.
If you are a participant in the Oklahoma Health Professionals Program (OHPP), whether voluntarily or by Board Order, you may respond "NO" to the following question.
  
    Yes No
P.Since your last renewal or initial licensure (whichever is most recent), have you had any mental disorder, physical condition, or substance use disorder (including alcohol) that is negatively impacting your work or is likely to have a negative impact on your work in the future?   X







I, the undersigned, have to the best of my knowledge, complied with the laws and rules regulating my profession. I hereby state that the information contained in this application is true and correct.
Signature of Applicant:   Date:   Time:  
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