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Form 4 - Verification of Professional Practice of Medicine in Another Jurisdiction

Use this form only if you are requesting licensure based on endorsement of another license.

Please Note: This form must be sent to the Office of the Professions by the licensed physician verifying your practice. We will not accept this form if it is submitted by the applicant.

  • Section I: Complete this section of the form before sending it to the licensed physician verifying your professional practice of medicine. More than one form may be necessary to verify the total number of years of professional practice required for endorsement.
  • Section II: The licensed physician must complete this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 4 as needed.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.