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Pursuant to LAC 46XLV.422, a physician participating in postgraduate medical... state by way of registration, permit or license, shall report...

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Pursuant to LAC 46XLV.422, a physician participating in postgraduate medical... state by way of registration, permit or license, shall report...
School of Medicine
Office of Medical Education
Pursuant to LAC 46XLV.422, a physician participating in postgraduate medical training in this
state by way of registration, permit or license, shall report and shall request that the training
program report to the Louisiana State Board of Medical Examiners (LSBME) in writing the
suspension, termination, non-renewal, surrender, resignation or withdrawal of the physician’s
participation in training for any reason other than impairment by drugs or alcohol within thirty
days of such action. To comply with this requirement, I, the undersigned, do hereby consent and
give authority to LSU and its representatives to notify the LSBME in writing the suspension,
termination, non-renewal, surrender, resignation or withdrawal of my participation in training in
my GME program(s). Should I revoke this release at anytime LSU will notify the LSBME of
such revocation.
________________________________________
Print Name
___________________________
Department
________________________________________
Signature
__________ ______________
HO Level
Date
2020 Gravier Street, Suite 602 • New Orleans, Louisiana 70112
Office 504-568-4006 • Fax 504-599-1453 • www.medschool.lsuhsc.edu/medical_education
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