1995

INSTRUCTIONS
FOR
SECTION 2113 APPOINTMENTS
FROM
THE DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA

JULIE ZAMOYSKI
SR. ADMINISTRATIVE ANALYST
DEAN’S OFFICE, ROOM 12-138 CHS
LOS ANGELES, CA 90095-1722
Telephone # (310) 825-7050 or (310) 825-7059
Fax # (310) 267-2269

PART I To be completed by the Department

PART II To be completed by the Applicant

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PART I THE DEPARTMENT MUST PROVIDE THE FOLLOWING INFORMATION

1. Complete the attached Special Programs 2111/2113 Administrative Processing Sheet

2. Write a letter requesting the Dean’s Office support for a Section 2113. See enclosed sample.

3. Make sure the 2113 Applicant has completed the form and provided the required items. See INSTRUCTIONS FOR THE 2113 PHYSICIAN APPLICANT.

4. Submit applications in a timely manner.

5. Read the 2113 General Information Sheet.

2113 GENERAL INFORMATION

The Medical Board must have all items before it will issue a Certificate of Registration. If the Medical Board believes a faculty member is immediately licensable it may deny the Section 2113 request.

The purpose of the Section 2113 Certificate of Registration is to allow a faculty member, who holds a 100% appointment, of a California medical school the right to practice medicine within the scope of the faculty appointment. The Certificate does not allow the faculty member to open a private office outside of the UCLA faculty position.

The Certificate will be issued for one year at a time; it may be renewed annually for a total of 5 years. The Medical Board has the discretionary authority to require that the faculty member obtain an ECFMG Certificate prior to issuing a renewal of a 2113 Certificate.

The Licensing Section of the Dean’s Office will send out a memorandum to Departments approximately 90 days before the 2113 Certificate expires requesting approval to renew the Certificate.

MEDICAL BOARD 2111/2113
Application Submission

Special program applications will no longer be presented at the Medical Board meetings. Please allow 60-90 day processing time.

SEND APPLICATIONS DIRECTLY TO:
Julie Zamoyski, Dean’s Ofc. Room 12-138 CHS
UCLA School of Medicine, Los Angeles, CA 90095 -1722

My office telephone number is (310) 825-7050, fax # (310) 267-2269

Please make sure signatures have been obtained on the Department request letter before sending the application to me. Please do not send applications directly to Neil Parker.

INSTRUCTIONS FOR WRITING THE DEPARTMENT LETTER TO REQUEST A SECTION 2113 CERTIFICATE OF REGISTRATION

Address the letter to:

Dr. Fawzy I. Fawzy
Senior Associate Dean, Academic Affairs
Dean’s Office, Room 12-138 CHS
Los Angeles, CA 90024-1722

Re: Name of physician

Dear Dr. :

This is to request a Section 2113, Certificate of Registration, for Dr. X_________, who will serve as (UCLA faculty title), in the Department of X___________. He or she will be located at (enter the name of the campus such as UCLA Medical Center, Cedars-Sinai Medical Center, Harbor-UCLA Medical Center, etc.). *note – include the name and title of faculty under whose direction the 2113 will serve while at UCLA or an affiliated hospital.

Dr. X_________ will (describe the teaching, research, and clinical activities; provide sufficient details to enable physicians with the Medical Board to determine patient interaction.) *note - include a statement that explains to the licensing division the correlation between clinical activity and teaching - what are the clinical duties and how do those duties relate to what the 2113 faculty will be teaching?

Dr. X_________ will be subject to the same disciplinary procedures that are customarily followed in this department.

Sincerely,

Name Chairperson (or designee)
Title

*Please note that this sample letter serves as a guideline only, and that individual circumstances should be noted.

PART II THE 2113 APPLICANT MUST PROVIDE THE FOLLOWING:

1. SEE ATTACHED INSTRUCTIONS FOR THE 2113 PHYSICIAN APPLICANT

2. COMPLETE THE ENCLOSED 2113 APPLICATION FORM

3. RETURN THE FORM WITH THE REQUIRED ITEMS TO THE DEPARTMENT THAT WILL BE RECOMMENDING YOU FOR THE 2113. Do Not Send items directly to the Medical Board or the Dean’s Office

INSTRUCTIONS FOR THE 2113 PHYSICIAN APPLICANT

COMPLETING THE 2113 APPLICATION FORM

Please complete the attached 2111 Application Form. Answer all question blanks. Do not leave blanks. Check YES or NO where appropriate, or write NONE or N/A (not appropriate)
Attach 2 photographs (A proof photo is not acceptable.)
Make sure you sign and date the application form.

ATTACH THE FOLLOWING ITEMS TO THE FORM

1. A copy of your Curriculum Vitae (same as resume)

2. The original and a copy of your medical school diploma in the language of your country, along with an English translation, if the diploma is not in English. The State of California DOES NOT accept the Certificate of Graduation in place of a medical school diploma. (A copy of just the English translation is not sufficient; copies of both the original language diploma and translation are required.)

3. A copy of your License to practice medicine issued by your home country, with an English translation. (A translation alone is not sufficient.)

4. If your country does not have a license, a letter from the agency or hospital that gives you the right to practice medicine is required.

5. An original Letter of Good Standing or Certificate of Good Standing, with an English translation, from the Ministry of Health or Medical Council that issued your license to practice medicine. Letters from employers are not accepted, unless the applicant is from the People’s Republic of China. All letters must state that "no disciplinary actions" have been taken against the physician.

6. A copy of your Residency Certificate or written verification that you have completed 3 years of basic residency training. If the original language is not in English, an English translation is required.

7. A copy of your ECFMG Certificate, if you are a foreign medical school graduate.

8. A copy of your FLEX, NBME, USMLE, or LCME scores.

9. If you are already in the United States, a copy of your I-94 arrival document.

10. If you are a permanent resident or US citizen, provide a copy of your Resident Alien Card, Employment Authorization Card, US passport or birth certificate.

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