30 E. Broad St., 3
rd
Floor
Columbus, Ohio 43215
(614) 466-3934
www.med.ohio.gov
Background Check Packet
State Law requires all individuals applying for or restoring a license with the State Medical Board of Ohio to
submit fingerprints for a criminal record check completed by both the Ohio Bureau of Criminal Investigation
(BCI) and the Federal Bureau of Investigation (FBI).
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in the FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28 CFR 16.34.
Ohio Revised Code (ORC) Reasons for Fingerprinting
License Type ORC #
4731.08
4731.
08
4730.
101
4731.
171
4762.031
4760.
032
4774.
031
4778.
04
4761.
051
4761.
051
4759.061
4759.061
Physician
Podiatrist
Physician Assistant
Massage Therapist
Acupuncturist
Anesthesiologist Assistant
Radiologist Assis
tant
Genetic Counselor
Respiratory Care Professional
Respiratory Care Limited Permit
Licensed Dietitian
Dietetics Limited Permit
Fingerprinting Instructions
There are two options for completing the background checks:
OPTION 1 – Ohio Fingerprint Services (Approximate Processing Time: 2 Weeks)
The State Medical Board of Ohio recommends electronic prints when possible. If you are located in Ohio or
can make yourself present in Ohio, you must submit electronic prints via the National Webcheck Program.
An approved Ohio WebCheck facility can be located at https://www.ohioattorneygeneral.gov/
backgroundcheck. Once you have located a Webcheck facility near you:
1. Call the fac
ility to schedule an appointment and verify requirements for fingerprinting at that location.
Generally, you will need:
• A valid, gov
ernment-issued photo ID
• Form of payment
• Reason for fingerprinting. You must provide the correct ORC # (see above for appropriate
ORC # for the license being applied for).
2. Have the Webc
heck facility select “direct copy” from the dropdown box for the State Medical Board of
Ohio, located at 30 East Broad Street, 3rd Floor, Columbus, OH 43215.
OPTION 2 – Out-of-State Fingerprint Services (Approximate Processing Time: 4 Weeks)
If it is not possible to appear in Ohio for electronic fingerprinting through WebCheck, you will need to print two
of each fingerprinting cards below and complete the fingerprinting as follows:
1. Contact an entity that can perform ink fingerprinting on cards, or can print cards with fingerprints taken
electronically, and verify requirements for fingerprinting at that location. Fingerprinting can be completed
by most local law enforcement agencies. Generally, you will need:
• A valid, government-issued photo ID
• Form of payment
• Reason for fingerprinting. You must provide the correct ORC # (see above for appropriate
ORC # for the license being applied for).
2. Complete the fingerprinting of four cards at the identified location
a. Verify that the top left-hand corner indicates APPLICANT on two cards and BCI on the other two
cards. Some locations may require you to use fingerprinting cards of their own. You may strike
through APPLICANT on two of the cards and remark them BCI.
b. Complete the top portion(s) of the fingerprinting cards (see the fingerprint example provided
below). You must provide the correct ORC # (see above for appropriate ORC # for the license
being applied for).
3. Mail two fingerprinted cards (one APPLICANT and one BCI card) with payment for processing. It is the
responsibility of the applicant to mail the fingerprint cards.
a. Obtain a money order, personal check, or business check for payment (cash is not accepted as
payment) in the amount of $47.25. This fee covers both the BCI and FBI background check.
b. Make the check or m
oney order payable to Treasurer, State of Ohio
c. Place two fingerprinted cards (one APPLICANT and one BCI card) in an envelope with the
payment and mail them to:
Ohio Bureau of Criminal Investigation (BCI)
PO Box 365
London, Ohio 43140
d. Retain the other two fingerprinted cards in case the prints are rejected. If the fingerprints are
rejected, you must resubmit a second s
et of prints. Mail the two retained cards with the
rejection notification. There should not be an additional charge for the additional processing so
long as the rejection notice is provided with the second submission.
FBI Card Example
Note: printable cards on the next two pages
Mailing Example
It is recommended that Priority Mail, including USPS tracking, be used so that you can
c
onfirm delivery to BCI.
FD-258 (REV.12-10-07)
LEAVE BLANK
BCI
TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANK
LAST NAME FIRST NAME MIDDLE NAME
NAM
ALIASES
AKA
DATE OF BIRTH
DOB
Month Day Year
PLACE OF BIRTH
POB
SEX RACE HGT. WGT. EYES HAIR
LEAVE BLANK
CITIZENSHIP
CTZ
YOUR NO.
OCA
O
R
I
CLASS
REF.
FBI NO.
FBI
ARMED FORCES NO.
MNU
SOCIAL SECURITY NO.
SOC
MISCELLANEOUS NO.
MNU
SIGNATURE OF PERSON FINGERPRINTED
RESIDENCE OF PERSON FINGERPRINTED
DATE
EMPLOYER AND ADDRESS
REASON FINGERPRINTED
SIGNATURE OF OFFICIAL TAKING FINGERPRINTS
1. R. THUMB 2. R. INDEX 3. R. MIDDLE 4. R. RING 5. R. LITTLE
6. L. THUMB 7. L. INDEX 8. L. MIDDLE 9. L. RING 10. L. LITTLE
L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLYLEFT FOUR FINGERS TAKEN SIMULTANEOUSLY
* See Privacy Act Notice on Back
Required for licensure per ORC
OHBCI0000
STATE BUREAU
LONDON, OH
STATE MEDICAL BOARD OF OHIO
30 E. BROAD ST., 3RD FLOOR
COLUMBUS, OH 43215
1AB002
ORC#
FD-258 (REV.12-10-07)
LEAVE BLANK
APPLICANT
TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANK
LAST NAME FIRST NAME MIDDLE NAME
NAM
ALIASES
AKA
DATE OF BIRTH
DOB
Month Day Year
PLACE OF BIRTH
POB
SEX RACE HGT. WGT. EYES HAIR
LEAVE BLANK
CITIZENSHIP
CTZ
YOUR NO.
OCA
O
R
I
CLASS
REF.
FBI NO.
FBI
ARMED FORCES NO.
MNU
SOCIAL SECURITY NO.
SOC
MISCELLANEOUS NO.
MNU
SIGNATURE OF PERSON FINGERPRINTED
RESIDENCE OF PERSON FINGERPRINTED
DATE
EMPLOYER AND ADDRESS
SIGNATURE OF OFFICIAL TAKING FINGERPRINTS
1. R. THUMB 2. R. INDEX 3. R. MIDDLE 4. R. RING 5. R. LITTLE
6. L. THUMB 7. L. INDEX 8. L. MIDDLE 9. L. RING 10. L. LITTLE
L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLYLEFT FOUR FINGERS TAKEN SIMULTANEOUSLY
* See Privacy Act Notice on Back
REASON FINGERPRINTED
Required for licensure per ORC
1AB002
OHBCI0000
STATE BUREAU
LONDON, OH
STATE MEDICAL BOARD OF OHIO
30 E. BROAD ST., 3RD FLOOR
COLUMBUS, OH 43215
ORC#
