US Medical Licensing
For all your licensure amd credenitaling need assiting physicians in all 50 States - 615.618.4412 - 845.625.1540

Medical License

 physician credentialing
The process of obtaining a physician's state license is an endless stream of paperwork and procedures.  Whether you are an established physician with a busy medical practice, or a overworked resident trying to complete your training, it is difficult to devote the time and energy that is required to research and complete the application process for your medical license.
 
dea registration
US MEDICAL LICENSING
2303 n 44th Street
Suite 14-1076
Phoenix, AZ 85008
Phone (615) 733-2754


RELEASE & WAVIER of RIGHTS

I,                          ,MD hereby authorize the following entities and individuals to release all information in their possession including transcripts, concerning me, whether oral, in writing, documented or other, to US Medical Licensing and/or its agents Michelle Vona or Tina Waller acting on my behalf;
  1. All medical/osteopathic school or undergraduate schools/universities which I have attended
  2. All hospitals or health care facilities at which I have ever held staff privileges, whether full or limited, temporary or permanent; and all hospitals or health care facilities at which I have ever received training; any hospital, health care facility, and/or treating physician from which I have received treatment.
  3. All medical/osteopathic societies, specialty boards, and other medical/osteopathic organizations with which I have ever been associated.
  4. All agencies from which I have, in the past or present, obtained malpractice insurance coverage from.
  5. All attorneys who have ever participated in criminal or civil actions in which I was named party, that would pertain to or directly affect my ability to obtain state medical license, practice medicine and/or have clinical privileges.
I hereby release the above named entities and individuals from all liability for the release of information to the state board, US Medical Licensing, and/or its agents.

I hereby agree to make this RELEASE and WAIVER of RIGHTS for the purpose of allowing US Medical Licensing and/or its agents, to execute its duties pursuant to my request for a license to practice my profession. I further authorize USML or any of its authorized agents to make investigations that they deem necessary to secure information concerning me that is relevant to the requirements of licensure.



Signature

Date
 

SS#

DOB


This is to certify that the above RELEASE and WAVIER of RIGHTS was signed

by
, the
day of
, 2011.



SEAL

NOTARY PUBLIC
My Commission Expires: