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Verification of acgme approved graduate medical training form

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The document outlines the verification process for ACGME approved graduate medical training for graduates of unaccredited medical schools. It specifies the requirements for training duration based on the start date, details the necessary sections to be completed by both the applicant and program director, and includes instructions for submission to the State Board of Medicine.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated fields: Last, First, and Middle. Ensure accuracy as this information is crucial for verification.
In Section 1, provide details about your training history. If applicable, indicate the years of approved training based on the guidelines provided.
For Section 2, input the hospital name where your training occurred along with the sponsoring institution's details. Make sure to include city and state.
Fill in the PGY level, dates of training (from MM/DD/YYYY to MM/DD/YYYY), and specialty for each year of training completed. Confirm that all information aligns with ACGME accreditation requirements.
Finally, have the program director sign and date the form. If necessary, arrange for notarization if there is no official seal available.

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