1/19/2021 Electronic Portfolio of International Credentials (EPIC) - Physician Portal

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Getting StartedBiographicsMedical SchoolMedical Registration/LicensurePhoto/PassportSummaryPayment

Print Summary
Request to Establish an EPIC Account Summary

The information you provided in response to each item in the request to establish an EPIC account is summarized
below. You should review all of your responses carefully before submitting this information to ECFMG. Use your
browser’s print function to print this page for your records.

Biographic Information
Your Biographic Information
Last Name(s): Hashemian
Rest of Name: Hosein
Generational Suffix:
Date of Birth: 04 April 1989
Gender: Male
Birth Country: IRAN
Birth City:
Birth State/Province:
Citizenship At Birth: IRAN
Citizenship Upon Entering Medical
IRAN
School:
Current Citizenship: IRAN

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U.S. Social Security Number:

National Identification Number:
National Identification Number Country:
Do you have a USMLE/ECFMG
NO
Identification Number?
USMLE/ECFMG Identification Number:
Do you have an ECFMG International
Credentials Services (EICS) Identification NO
Number?
EICS Identification Number:
Contact Information
Address of Residence: Isfahan
IRAN
E-mail Address: Hashemian@ariantmh.com
Telephone Number: Fax Number:

Medical School Information

Degree Medical School
Indicate whether you are currently a
GRADUATE
medical school student or graduate:
Official Name of the Medical School: Tehran University of Medical Sciences School of Medicine
University Name (If Applicable):
School Address: Tehran University of
Medical Sciences School
of Medicine
P.O. Box 14155-6447
1417613151 Tehran
IRAN
Attendance Dates: Start: May 2010 End: April 2019
Student Identification Number:
Date Medical Degree Was Issued or Is
February 2020
Expected to Be Issued:
Title of Medical Degree: Primary Medical Degree
Other Undergraduate Medical School(s) Attended
No other undergraduate medical schools attended were added.

Medical Registration/Licensure
Medical Registration/Licensure
Authority with which you were or are registered as a medical practitioner or that issued you a license to practice
medicine:

Authority Name: Medical Council of Iran

Address: P.O. Box 11365-3759
No: 6-8, Farshi Moghaddam St.
North Kargar Ave
Tehran 14398-37953
IRAN

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Organization(s) to Which I Am Applying

General Medical Council

Photograph/Passport
Your Photograph/Passport

Photograph

Passport
Expiration Date: 08-February-2023

Certification by Applicant

Release of Legal Claims, Waiver of Liability, Indemnification, and Hold Harmless Statement

I hereby release ECFMG, its Board of Trustees, officers, directors, employees, committees, and the agents of each of
them (collectively, "ECFMG") of and from any and all liabilities, complaints, claims, lawsuits, damages, demands,
losses and expenses arising out of or in connection with any action or omission by ECFMG in connection with this
request, the request process, any investigation of my credentials and documents, any investigation or finding of
irregular behavior, any failure or refusal to issue a report, or any other related activities involving ECFMG (collectively,
"Claims") whatsoever I may have, now and in the future, in consideration for the opportunity to establish an EPIC
account.

I also hereby agree to indemnify and hold harmless ECFMG with respect to any and all Claims (including ECFMG's
reasonable attorneys' fees). I understand that the decision as to whether I qualify for an EPIC account rests solely
and exclusively with ECFMG and that ECFMG's decision-making authority is ongoing.

I HAVE READ AND I UNDERSTAND THIS RELEASE OF LEGAL CLAIMS, WAIVER OF LIABILITY,

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INDEMNIFICATION, AND HOLD HARMLESS STATEMENT, AND I INTEND TO BE LEGALLY BOUND BY IT.

By checking this box, I confirm that I have read, understood, and agree to the Release of Legal Claims, Waiver of
Liability, Indemnification, and Hold Harmless Statement as described above.

Release of Information Authorization

I authorize every person, medical school, university, hospital, government agency, or other entity to release
information to ECFMG, including, but not limited to, records, diplomas, transcripts, and other documents concerning
my identity, citizenship or immigration status, educational, academic or professional history and status, or enrollment.

I hereby authorize ECFMG to transmit any information in its possession, or that may otherwise become available to
ECFMG, bearing on the content of my request or any other document submitted to ECFMG, including, but not limited
to, records, diplomas, transcripts, and other documents concerning my identity, citizenship or immigration status,
educational, academic or professional history and status, or enrollment, and determinations of irregular behavior to
any federal, state, or local governmental department or agency, to any hospital or to any other organization or
individual who, in the judgment of ECFMG, has a legitimate interest in such information.

I also extend absolute immunity to, and release, other agencies, medical schools, universities, institutions, hospitals
and clinics, and registration and licensing authorities providing information, their employees, representatives,
directors, and officers, and any third parties and organizations for their acts, communications, reports, records,
diplomas, transcripts, statements, documents, recommendations, or disclosures involving me, made in good faith and
without malice, requested by ECFMG.

I HAVE READ AND I UNDERSTAND THIS RELEASE OF INFORMATION AUTHORIZATION AND I INTEND TO BE
LEGALLY BOUND BY IT.

By checking this box, I confirm that I have read, understood, and agree to the Release of Information Authorization
as described above.

Information regarding how ECFMG may collect, use and disclose my personal information in connection with the
programs and services offered by ECFMG is set forth in ECFMG’s Privacy Notice and is available on the ECFMG
website at www.ecfmg.org.

By checking this box, I confirm that I have read, understood and agree to the ECFMG Privacy Notice.

Use Of Credentials

I hereby authorize ECFMG to transmit to my EPIC account any medical education credentials previously primary-
source verified by ECFMG in support of my application to another ECFMG program or service, including ECFMG
Certification and the ECFMG International Credentials Services (EICS).

Certification

By checking this box, I hereby certify that the information in this request to establish an EPIC account is true and
accurate to the best of my knowledge and I hereby certify that I have read, understood, and agree to all of the above
statements. I also certify that I have read the ECFMG Policies and Procedures Regarding Irregular Behavior and
agree to abide by these policies and procedures. I certify I understand that, as provided in the ECFMG Policies and
Procedures Regarding Irregular Behavior, among other things, ECFMG may find that submission of falsified
documents to ECFMG through EPIC constitutes irregular behavior, which could result in actions including permanent
revocation of or permanent bar to ECFMG Certification, among other things.

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Amount Required to Process Your Request to Establish an EPIC Account US$130.00

Proceed To Payment
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