(a) For purposes of subdivision (b) of section 2236.2 of the Code, “notice” means a statement signed under penalty of perjury and dated by the licensee and provided to the board by means of a facsimile transmission, regular mail, or personal service at the option of the licensee. The statement shall include the date and time of the licensee's release, his or her physician's and surgeon's certificate number, and the name and location of the facility at which the licensee was formerly incarcerated.

(b) Whenever a license is placed on inactive status pursuant to section 2236.2 of the Code, the board shall display the status of the license as follows: “Inactive License -- Misdemeanor Conviction. Licensee was convicted of a misdemeanor and is currently incarcerated. No practice is permitted.”