2014 new hire full medical license and temporary educational permit licensing instructions
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2014 New Hire Full Medical License and Temporary Educational Permit Licensing Instructions. This presentation is intended for incoming upper-level residents who are not licensed or only have their Temporary Educational Permits. - PowerPoint PPT PresentationTRANSCRIPT
2014 New Hire Full Medical License and Temporary Educational
Permit Licensing Instructions
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This presentation is intended for incoming upper-level residents who are not licensed or only have their Temporary Educational
Permits.
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PG-1 with Prior GME and PG-2s: Complete the Temporary Educational Permit and Full License Application.– Read through entire PowerPoint
PG-3 and above (or if you already possess your TEP): Complete the Full Medical Licensure Application only.– Slides 14-35
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Go to the Wisconsin Department of Safety and Professional Services website http://dsps.wi.gov/Home
Select Application Forms Select Health Professionals Select Physician Select Licenses/Permits/Registrations/Application Forms Select Application for Endorsement/Reciprocity or Re-
registration and/or Temporary Education Permit– If you already held a license with the State of Wisconsin, you must apply as a re-
registration.
Print each of the forms listed.
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Documents to gather:Is your name correct on all your documentation? (diploma)
If not, make 1-2 copies of the legal documentation (marriage certificate, divorce decree, etc.) to be included with the: Application for Full Licensure (Form 570) Application for TEP (Form 564) – PG-2s only
ECFMG Certificate, if applicable
Envelopes: Manila envelope (8 ½ x 11) to: Wisconsin Dept of Safety &
Professional Services, PO Box 8935, Madison, WI, 53708-89353 white envelopes
Medical Education Verification Form to address to your Medical School If prior GME - Certificate of Post-Graduate training in a Non-UWHC GME training
program, if applicable Federation of State Medical Boards – USMLE Step Scores
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What does the GME Office pay for?Licensure PG-2 only: The hospital will
reimburse the initial license application fee $150 (Endorsement of Steps 1,2,3) upon receipt of full licensure within your PG-2 year at UWHC. You are required to pay the initial license fee up front.
PG-3 and above Licensure fees will be your responsibility.
Residents are responsible for all other licensure and examination fees.
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DEA FeeThe GME Office will pay the initial and renewal fee of $731.
If your DEA comes up for renewal during your last year of training it will be your responsibility to renew your DEA for the full cost. You will be reimbursed a prorated amount for the months left in your program.
If you are in a one year ACGME training program you will need to order/renew the DEA number on your own. You may submit a reimbursement request to the GME office for the cost of the 12 months during your one year of training
The GME Office will apply for your initial DEA automatically when you are fully licensed.
Upper Level Residents who currently hold a DEA contact Cindy Feuling, [email protected]. 7
PG-1s with Prior GME
and PG-2’s
How and when
to apply for Step 3
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As a PG-2, in order to meet the UWHC-GME March 1, 2015 deadline for obtaining full licensure by your PG-3 year, register for the current Step 3 exam by June 15, 2014. This is to ensure you are able to sit for your exam in time.
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Why you need to register by June 15, 2014
Restructuring of Step 3Registration for the current Step 3 examination will end July 31, 2014. Registration for the restructured Step 3 examination will begin August 2014. No Step 3 examinations will be administered during most or all of October 2014. There will be a substantial score delay following introduction of the restructured Step 3 examination in November 2014. The duration of the score delay will be determined by examinee volume during the early months of exam administration. Based on historic trends, we estimate that the first scores for Step 3 exams taken on or after November 1, 2014 will be released during the first week of April 2015, which is too late to meet the March 1, 2015 deadline to be fully licensed.
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How to register for USMLE Step 3Federation of State Medical Boards (FSMB) website
http://www.fsmb.org/usmle_apply.html Identify a State Board – indicate a no-requirement state(Arkansas. California, Connecticut, Delaware, Florida, Nebraska, New York, North Carolina, Virginia, West
Virginia) – do NOT register through Wisconsin!!
Complete the USMLE Step 3 Application (orange button) Provide an email address as this is the primary means of
communication by the FSMB. Print and mail the Certification of Identity form (2x2 Picture / Notary)
Fee for 2013/2014 is $800. Must be paid by Visa, Mastercard, ACH (bank routing) transaction
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Indicate which no-requirement state licensing agency you will be taking Step 3 through.
2 x 2 colored picture attachedNeeds to be notarizedSend to the address at the bottom of the form.
For Notarization: Do NOT sign your form ahead of time. Bring your unsigned form to a notary (they can be found at banks and government establishments) along with an ID such as a driver’s license.
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DO’s Only – if taking COMLEX only
Schedule COMLEX Level 3 Exam http://www.nbome.org
Review COMLEX-USA Exam Dates 2014
Log into the NBOME Client Registration System to schedule exam date.
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Timing your Step 3 Exam Window Register no later than June 15, 2014 to take Step 3 before
September 30, 2014. Complete Step 3 application, indicating a “no requirement”
State Submit Certificate of Eligibility, indicating same “no
requirement State” Receive email response from the FSMB in 7-10 days after
completion of your application Receive an e-mail from the FSMB within 2-4 days for Step 3
exam permit. The permit will provide a 90 day window to register and take the exam.
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Full Licensure Application for
License to Practice Medicine and Surgery
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If you previously held a State of Wisconsin Medical License and it has lapsed, apply as a Re-registration.PG-2 Wisconsin LicensingPG-3 and above Wisconsin licensing
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Form 570Page 1 of 6
Select which endorsement is appropriate:MD or DO–
Endorsement of Steps 1,2,3 of USMLE•Applying to take USMLE Step 3through a no requirement state
•Have already taken Step 3Check the blue box
Include a check for $150
DO – Endorsement of NBOMETaking COMLEX 3 Check the red box
Include a check for $150
Program Specialty Code on next page.
Attach check made out toSafety & Professional Services
Envelope addressed to:Wisconsin Dept of Safety & Professional
ServiceP.O. Box 8935
Madison, WI 53708-8935
X
Last Name First Name
Street Address, City State Zip
Month Day Year Telephone
Medical SchoolCity, State
MD or DOMS Grad Date
X
Program SpecialtyProgram Specialty
Code from next page
X
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Form 570Page 2 of 6
Do not leave gaps of more than 30 days betweenMedical School graduationAnd starting residency.
Enter Undergraduate Information
Your Medical School Address Grad Date
Vacation/Relocation Grad Date– 6/20XXPrior GME Institution Start Date – 6/20XX
Attention IMGs
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Were you a Nurse/Pharmacist? Address Grad Date
Do not leave any gaps
UWHC 600 Highland Avenue Madison, WI 53792 6/20XX - present
Form 570Page 3 of 6
If you have been previously licensed,complete the middle section .
You will also need to Obtain documentation from
that Licensing Board.
Enter any institutions where you had staff privilegesin the last 5 years – e.g. moonlighting. Do not list if you were only there as a traineeResearcher / Nurse / Pharmacist
If you’ve been licensed before – i.e. Nurse or Pharmacist
Failed Exam?Provide an explanation
Conviction for DWI, disorderly conduct , underage drinking?
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Form 570Page 4 of 6
Questions 15-16-17 are poorly worded
answer Yes or N/A (instead of No)
N/A
N/A
N/A
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Print Name Here
Form 564Page 5 of 6
Needs to be notarized.
Do NOT complete until you arein front of a notary!
WI Dane
Current DateSignature
Select one
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Form 570Page 6 of 6
The DSPS will contact you by email regarding any pending
items.
DSPS Envelope
First Name Middle Initial Last Name
Medical Resident
Date of Birth (MM/DD/YYYY)
Social Security Number
X
Your current email
Form 571
This form must be notarized, original is included with
full application.
Do NOT complete until you arein front of a notary!
DSPS Envelope
Name Place of Birth Date of Birth
Your Signature
WI Dane
Print Name
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Form 1445
White Envelope addressed to:Federation of State Medical
Boards, INC (FSMB)400 Fuller Wiser Rd Ste 300
Euless, EX 76039-3855
Note! DO NOT send to DSPS they will not process
or return the form.First Name MI Last Name Degree
Date of Birth Social Security #
Medical School Name MM/DD/YYYYDate of Graduation
ECFMG # if applicable
Physician’s Signature
MM/DD/YYYY todays date
Ignore this. These are directions for the FSMB.
Form 2164
White Envelope addressed to your Medical School
Your NameMedical School Name
Medical School Address
SSN #
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Ignore this. These are directions for the school.
Form 1934
Begin with your Residency for PG1/2 or hospital appointment
work backwards and conclude with graduation from medical school
Do not leave any gaps of more than 30 days.
DSPS Envelope
Last First MI
Street, City, State, Zip
MM DD YY
Current DateMaiden/Given Surname
University of WI Hosp & Cls Program - Resident
Prog Director
Current
600 Highland Ave Madison WI 53792
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Previous GME Info
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Form 2167
If this does not pertain to you write your name and Not Applicable at the top
and include in the DSPS Envelope
If you have been employed during the past 5 years
(after Medical School graduation), in a position other than GME trainee,
you must send one of these forms to each employer.
Fill in the top portion and address an envelope to the Facility/Employer
Medical Staff Office.
White Envelope (s) – addressed to facility/facilities if applicable
Not Applicable
First Name MI Last Name
Form 2252Page 1 of 2
If you have no convictions or charges , do not submit this form.
Read question 2 carefullyIf you have convictions orpending charges such as
alcohol violations, including underage drinking, or
drug violations completethis form and attach the required
documentation.
This form will need to be notarized and include an $8 check payable to Safety & Professional Services.
For Full licensure and/or TEP Application, you must include a
Separate convictions form and an$8.00 check with each application.
A copy of the required Documentation will be needed for
each application as well.
Disregard unless you have
convictions and pending charges
to report
Last Name First Name
Home Address, City, State Zip
Date of Birth Social Security #
Offense Date City and State
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Form 2252Page 2 of 2
DSPS Envelope
Signature – if applicable Today’s Date
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First Name MI Last Name
Home Address
City State Zip
Form 2829 Page 1 of 2
If you have a notice of claim or a lawsuit pending,
complete this form.
If not, print your name and Not Applicable at the top.
DSPS Envelope
Not Applicable
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Documents submitted in the DSPS envelope Form 570 Application to Practice Medicine & Surgery (include in envelope after being
notarized) Form 571 Authorization and Waiver Form 1934 Work History Form 2167 Hospital Facility and Employer Verification only if not applicable Form 2252 Convictions and Pending Charges, if applicable Form 2829 Malpractice Suits or Claims Form Diploma and translation if applicable ECFMG certificate, if applicable Name change documentation, if applicable Staple the check to Page 1 of the application. Check is made out to the Dept of Safety &
Professional Services for $150
Documents submitted in separate envelopes FSMB – Disciplinary Inquiry Report Form 2164 Medical Education Verification addressed to Medical School If prior GME – Certificate of Post-Graduate Training address envelope
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Additional reports to be completedPrior to taking Step 3
AMA- MD Physician Profile Data – https://profiles.ama-assn.org/amaprofiles/ $37.00 fee / credit card
OR DOs Physician Profile Data – Form 1935, Request for
Physician Profile Data No fee FSMB Disciplinary Inquiries Report (Form 1445) No fee
After passing Step 3 or COMLEX complete the NPDB (National Practitioner Data Bank) Self-Query $8.00 fee credit card
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Google: AMA Profile Service
MDs only
Select Physicians Only – Requests for profiles to
licensing Boards
No Fee when sent directly to a State Licensing Agency
Select this one
After passing Step 3 –
Request official transcript of USMLE
Step 1, 2 CK/CS and 3 scores http://www.fsmb.org/transcripts.html
All requests are processed as they are received. FSMB issues transcripts within three business days of receiving the completed transcript request and appropriate fee. The FSMB will not hold a transcript request pending the release of scores at a later date. If you have recently taken an exam and need that score to appear on your transcript, do not send the request until you have received your official score report for that exam.
Fee $65.00 / 2 copies35
DO’s Only - After passing COMLEX
Request official transcript
For NBOME transcripts: go to http://www.nbome.org/transcript-request.asp?m=can
Submit an electronic request with the appropriate fee via the online registration system. Scores will be provided in the form of an NBOME transcript, which will contain scores for all COMLEX-USA examinations you have taken. No request for a transcript will be taken by telephone.
Have it sent to the WI licensing board.36
Temporary Educational Permit (TEP)
If a PG-2 you must have a medical license by your
clinical start date 6/24 or 7/1
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Form 564Page 1of 5
Include check for $10 madeout to Dept of Safety
& Professional ServicesReturn to:
UWHC-GME600 Highland Ave
Madison, WI 53792-8320The GME Office adds an
Affidavit.
Print Last Name First Name MI
Home Address City, State, Zip
MM DD YYYY Phone NumberOptional
X
Your Medical School City, State, Country
MM/DD/YYYY MD or DO Program
Vacation/Relocation 5/20XX – 6/20XX
University of Wisconsin Hospital Madison WI 6/20XX– present
Do not leave any gaps
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Conviction?DWI or UnderageDrinking ticket?
Failed Exam?Provide an explanation
Form 564Page 2 of 5
I M G
Questions 14-15-16 arepoorly worded. Only answer Yes or N/A.
Form 564Page 3 of 5
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N/A
N/A
N/A
Form 564Page 4 of 5
Do NOT complete until you arein front of a notary!
Print Name Here
WI Dane
Current DateSignature
Select one
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First Name Middle Initial Last Name
Medical Resident
MM DD YYYY
Social Security Number
X
Your current email
Form 564Page 5 of 5
Items to Include: Diploma, and translation if
applicable
If Applicable:•ECFMG certificate,
•Convictions & Pending charges form
•Name change documentation
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Disregard unless you have
Convictions and Pending Charges
to report
Form 2252Page 1 of 2
If you had no convictions this form does not need to be submitted
If you have convictions orpending charges such as
alcohol violations, including underage drinking, or
drug violations, completethis form and attach the required
documentation.
Include an $8 check payable to Safety & Professional Services
DSPS envelope
Last Name First Name
Home address
Social Security Number
Offense Date City and State
Date of Birth
Gender &Ethnic
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Form 2252Page 2 of 2
Today’s DateSignature
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How to monitor your license application progress
You should check the DSPS website weekly to monitor your application status.
Keep in mind it may take the DSPS 2-3 weeks to update your application status.
http://online.drl.wi.gov/LicenseLookup/IndividualCredentialSearch.aspx
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http://online.drl.wi.gov/ApplicationStatus/CredentialApplicationStatus.aspx
>Enter your last name>Select Profession:Medicine & Surgery MD (20)Medicine & Surgery DO (21)
How to check your status!
Wisconsin Statutes and Rules Examination
From your application status page the login and password will be provided.
This is an on-line open book exam. You can stop and start the exam as often as you like. It may take from 2-3 hours to complete.
If you fail the exam, there is a $75 fee to reset the exam. http://online.drl.wi.gov/LicenseLookup/
IndividualCredentialSearch.aspx
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User name and
password located
on your application
status page.
As you see by the title – Requirements not met these items need to be addressed. Therequirements are in red in the left column.
These are Requirements Met, they are in green on the left column.
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Licensing SessionComplete the NPDB self query after
your USMLE/COMLEX scores have been
posted on your DSPS application status
page.
Directions available in Med Hub /
GME Resources / Licensing
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