Get the free Order of Surrender of Medical License - w3 health state ny

This document serves as an official order from the New York State Board for Professional Medical Conduct regarding the surrender of Soren Jorgensen, M.D.'s medical license due to professional misconduct.

How to fill out order of surrender of

How to fill out Order of Surrender of Medical License

1. Obtain the Order of Surrender of Medical License form from the relevant medical board or authority.
2. Carefully read through the instructions provided with the form.
3. Fill in your personal details, including your full name, license number, and contact information.
4. Clearly indicate that you are voluntarily surrendering your medical license.
5. Provide a brief explanation for the surrender, if required.
6. Sign and date the form in the designated areas.
7. Submit the completed form to the appropriate medical board or authority via the specified submission method (mail, email, etc.).
8. Keep a copy of the submitted form for your records.

Who needs Order of Surrender of Medical License?

1. Medical professionals who are choosing to voluntarily surrender their medical license due to personal, legal, or professional reasons.
2. Physicians facing disciplinary actions or investigations may also consider surrendering their license as a proactive measure.

People Also Ask about

What are revocation terms?

A term used to describe the formal ending of a legal arrangement or order and a return to a previous arrangement.

What is a revocation in medical terms?

License revoked: Physician's license is terminated; individual can no longer practice medicine within the state or territory. License surrendered: Physician voluntarily surrenders medical license, sometimes during the course of a disciplinary investigation.

What is an example of a revocation?

If the library revokes your library card, you can no longer take out library books — that's a type of revocation. If a restaurant is dirty, that could result in the revocation of its health license. If a lawyer breaks the law, it could lead to the revocation of his license to practice law.

What does revocation mean in medical terms?

Revoked License or Certificate: If a doctor's license has been revoked, the doctor or other health care professional has had their license to practice medicine withdrawn by the Medical Board.

What is the full meaning of revocation?

noun. the act of revoking or state of being revoked; cancellation. the cancellation or annulment of a legal instrument, esp a will.

For pdfFiller’s FAQs

What is Order of Surrender of Medical License?

The Order of Surrender of Medical License is a formal document that a medical professional submits to voluntarily give up their medical license, often due to personal or professional reasons.

Who is required to file Order of Surrender of Medical License?

Individuals who wish to voluntarily relinquish their medical license, such as physicians or other licensed medical practitioners, are required to file the Order of Surrender.

How to fill out Order of Surrender of Medical License?

To fill out the Order of Surrender, the applicant typically needs to provide their personal information, details about their medical license, and a statement expressing their intention to surrender the license. It may also require a reason for surrender and a signature.

What is the purpose of Order of Surrender of Medical License?

The purpose of the Order of Surrender is to formally document the voluntary relinquishment of a medical license, ensuring that the medical professional is no longer authorized to practice medicine.

What information must be reported on Order of Surrender of Medical License?

The Order of Surrender must include the licensee's full name, medical license number, address, phone number, the reason for surrendering the license, and a signature confirming the surrender.