Connecticut Physician License Application 2023 Instructions

Submit your completed Connecticut Physician License Application along with the required checks to: CT DPH, Physician Licensing Application Processing, 410 Capitol Ave., MS# 12MQA, PO Box 340308, Hartford, CT 06134. Ensure all required fields are accurately filled out and include any necessary documentation. For questions or assistance, contact via email at dph.healingarts@ct.gov. Prepare checks payable to 'Treasurer, State of Connecticut.' Ensure your application arrives before any stated deadlines.

The application process for 2024-2025 remains the same. Ensure your application is submitted by June 30th to avoid any delays. Renewal notifications are sent out on September 1st each year.

The purpose of the Connecticut Physician License Application is to ensure that all practicing physicians in the state meet the necessary qualifications and standards. This form collects vital information such as personal details, educational background, and professional history. By completing this application accurately, physicians help maintain high medical standards and protect public health in Connecticut.

• 1. First Name: First name of the applicant.
• 2. MI: Middle initial of the applicant.
• 3. Last Name: Last name of the applicant.
• 4. Maiden Name: Maiden name of the applicant, if applicable.
• 5. Social Security Number: Social Security Number of the applicant.
• 6. Email Address: Email address of the applicant.
• 7. Street Address: Street address where the applicant resides.
• 8. Telephone Number: Phone number through which the applicant can be contacted.
• 9. Gender: Gender of the applicant.
• 10. Date of Birth: Applicant's date of birth.
• 11. City: City where the applicant lives.
• 12. Ethnicity: Ethnic background of the applicant.
• 13. Race: Race of the applicant, choosing from multiple options.
• 14. PHN: Personal Health Number.
• 15. Previous Licenses: Information about previously held licenses.
• 16. Current Licenses: Information about currently held licenses.
• 17. Examination Details: Details about the examination completed by the applicant.
• 18. Practice Intentions: Information about the applicant's practice intentions in Connecticut.
• 19. Malpractice Insurance: Details about the applicant's malpractice insurance.
• 20. Primary Practice Location: Location where the applicant will primarily practice.
• 21. Languages Spoken: Languages spoken at the practice location.
• 22. Hospital Privileges: Connecticut hospitals where the applicant has or will have admitting privileges.
• 23. Medical School: Information about the medical school attended by the applicant.
• 24. Post-Graduate Training: Details about the applicant's post-graduate training.
• 25. Specialty: Applicant's specialty area and certifications.
• 26. Subspecialty: Applicant's subspecialty area and certifications.
• 27. Publications: List of the applicant's publications and awards.
• 28. Teaching Positions: If applicable, teaching positions held by the applicant.
• 29. Disciplinary History: Applicant's disciplinary history in the past ten years.
• 30. Judgments: Details about any malpractice court judgments or settlements.
• 31. Felony Convictions: Information about any felony convictions in the past ten years.
• 32. Professional Memberships: Information about any professional memberships held by the applicant.
• 33. Notary Section: Section for notarizing the application.

Failure to submit the application can result in delays in processing or denial of a license. This may prevent physicians from practicing in Connecticut.

• Delayed Practice: You won't be able to legally practice medicine in Connecticut until your application is processed.
• Licensure Denial: Incomplete or incorrect applications can lead to denial of your license.
• Penalties: Practicing without a license can result in legal penalties.

• 1. New License: When applying for a new license to practice as a physician in Connecticut.
• 2. License Renewal: When renewing an expired or lapsed Connecticut physician license.
• 3. Relocation: When relocating to Connecticut and needing state licensure.
• 4. Post-Graduate Training: For medical graduates seeking to complete their training in Connecticut.
• 5. Reinstatement: When reinstating a suspended or previously held license.