upper level full licensing tutorial - uw health upper level... · usmle step iii application (form...
TRANSCRIPT
Upper Level Full Licensing
Tutorial
PowerPoint and Packet You will need to go tohttp://drl.wi.gov/index.htmto print the full licensure packet This PowerPoint and licensing packet is geared toward individuals who graduated from Medical School before the spring of 2009.
Licensing Session
Fees: What does the hospital pay for?DEA: The hospital will pay initial and/or renewal fees ($551) to cover your training period at UWHC.
We’ll apply for it automatically when we see you are fully licensed unless you already have a DEA number from another state.
During the last year of training we will reimburse you for a pro-rated portion of the DEA renewal fee.
Licensing Session
Licensing Session
MERCK LOAN
Available to all residents and fellows $1000 loan at 2% interestPayroll deducted over ten months or one lump sumMust be repaid in one calendar year.Application forms available in the GME office ~ H4/831
As soon as possible PGY-2 residents need to be licensed by their PGY-3 year. All residents who are a PGY-3 or higher, should be fully licensed by their hire date. PGY-3 and Above: You may get a temporary reprieve if you can show that you submitted all your materials for licensure and USMLE if hired a month before your start date. You should be fully licensed by the end of October the year you start.
Licensing Session
When should everything be submitted?
Name ChangesIs the name on all your credentials (diploma, USMLE scores) the same? If not, you must submit legal documentation (marriage certificate, divorce decree, etc.) of the change with your:
USMLE Step III Application (Form 13)Application for Licensure (Form 570)Application for TEP (Form 564)
Licensing Session
Address ChangesBe sure to keep both the
DRL and the USMLEinformed about any changesin your address. If you don’t, it may lead to missing deadlines and extra fees.
Licensing Session
Find yourspecialty code and enter into
Form 570 shown on
the next page.
X
Last Name First Name MI
Street Address, City State Zip
Month Day Year Telephone
Medical SchoolCity, State
Residency SpecialtyCode from Previous page
MD or DOMS Grad Date
X
X
program specialty
Check the blue box if you have already passedStep III or planning to take out of WI.
Form 570Page 1 of 6
If you are applying for
USMLE Step 3 and plan to take
the exam in Wisconsin,
check the boxindicated in green
on slide.Include a check
for $147
If you plan to take USMLE Step 3
out of stateor will be taking
COMLEX 3 check the box
indicated inblue on slide.Include a check
for $132
Enter Undergraduate Information
Your Medical School Address Grad Date
Do not leave any gaps
Vacation/Relocation 5/200? –
6/200?UWHC 600 Highland Avenue Madison, WI 53792 6/200? -
present
Attention IMG’s
Form 570Page 2 of 6
Do not leave gaps of
more than 30 days.
If you traveled,relocated or were on medical leave
in between positionsinclude.
Form 570Page 3 of 6
If you have ever been licensed before
you must fill out the middle section
ANDsend letters to each past
licensing board requesting verification
be sent to the WI DRL
Read the questions at the bottom carefully,
the most common answers are checked.
If you have failed a board exam, USMLE,
or Comlex
you will need to provide an
explanation on a separate piece
of paper.
Enter any hospitals where you have moonlighted or had staff privileges—most likely none
If you’ve been licensed before….
Failed Exam?
XX
X
X
X
X
X
X
Conviction?DWI or UnderageDrinking ticket?
Form 570Page 4 of 6
Read thequestions carefully.
Poorly Worded Questions. Only answer Yes or N/A.
Don’t leave blank
XXXXX
X
X
X
N/A
N/A
N/A
Print Name Here
Form 570Page 5 of 6
Page to be notarizedSignature
Check what applies
WI Dane
Today’s Date
Print First Name Middle Initial Last Name
Medical Resident
Date of Birth (MM/DD/YYYY)
Social Security Number
X
Your UWHC email
Form 570Page 6 of 6
Everyone must include:Copy of Diploma
Check Copy of Name
change documentation if applicable
Form must be notarized
Include in DRL envelope
The DRL will contact you by email regarding any
pending items.
Disregard unless you have
convictions and Pending Charges
to report
Last Name First Name Your address
Date of Birth Social Security #
Gender &Ethnic
Offense Date City and State
Form 2252
If you have convictions or
pending chargessuch as
alcohol violations,including
underage drinking,or
drug violationsyou must fill
out this form and attach the required
documentation.
This form must be notarized
and then include in
the DRL envelope with a $6 check.
$8Notary
DRL
Sign Here Today’s Date
Answer Questions
Form 2252
This form must be notarized
and include in
DRL envelope with a $8 check.
DRL
Your NameYour Medical School
Medical School Address
000-00-0000
Form 2164
This form goes into a blank
envelopethat you must
address to your
medical school Dean’s officeor Registrar.
Blank
Your Name
Hospital Address Form 2165
Complete if you had GME training prior
to UWHC.
Send to yourprevious program(s)
for verification.
Name/Last First MIHome Address
If you’ve used another name
MM DD YY
Today’s Date
Form 1934
Graduates of Spring 2009 complete
the top section as indicated.
PG-2’s and upmust complete
in chronological orderbeginning with your
current residencyworking backwardsto medical school.
Do not leave any gaps of more than
30 days. If you were traveling, relocating or on medical leave,
these must be included.
Include this form in the
small manila envelope to the DRL
DRL
Not Applicable
First MI Last Name
Form 2167Complete this form
if youhave had staff privileges
or did moonlightingin the past 5 years.
Research, if paidClinical Instructor
Worked in a medical clinic
Fill in the top portion and address a blank
envelope to the Hospital Medical Staff Office.
blank
If it does not pertain to you put your name and
Not Applicableat the top
and include in the small manila envelope to the
DRL
DRL
Name Place of Birth Date of Birth
Signature
WI Dane
Print Name
Form 571
This form must be
notarized.
After it is notarizedinclude in thesmall manila envelope to
the DRL.
DRL
Name
Your Address
City State ZipForm 2829
If you have a notice of
claim or a lawsuit pending, complete this
form.
If not, printyour name and Not Applicable
at the top.
DRL
Not Applicable
Signature Date
WIDane
Form 2829
This form needs to be notarized ifyou have a
claim against you.
After it is notarizedit goes into thesmall manila envelope to
the MEB.
MEB
Your Name
Your Home Address
City, State and Zip Code
MM/DD/YYYY
000-00-0000
Phone Number
Year of Grad for Med School
Sign Here
Attn: IMG’s
Today’s Date
Form 1935
For Osteopathsonly
Complete this form and include in the American Osteopathic Association
envelope.
Fees:AOA Members –
No Charge Non-Member -
$20.00
AOA
Last, First, Middle Name
Date of Birth (MM/DD/YYYY)
Degree
Medical School Year of Graduation
SSN
Attn: IMGs
Sign Here Today’s Date
Form 1445
ONLY
fill outif you have
passed Step 3 or are planning to
take it outside of Wisconsin.
Place in FSMB
Envelope
Do not leave
any gaps in time
No check necessary. Hospital will pay this for you.
Print Last Name First Name MI
Home Address
City, State, Zip
MM DD YYYY Phone Number
Optional
Your Medical School City, State, CountryMM/DD/YYYY MD or DO Program
Vacation/Relocation
5/200? –
6/200?University of Wisconsin Hospital
6/200? –
6/200?
X
Form 564Page 1of 5
Complete thisapplication
for yourtemporary permit
which will cover you until
full licensureis obtained.
If you are currently on a Temporary
permit, you do notneed to fill this out
Exception: If it’s due to expire within a month, you
will need to fillthis out again.
Form 564Page 2 of 5
Same questionsas on the
full licensure paperwork.
x
x
x
x
x
x
x
x
x
x
x
x
Failed Exam?
Conviction?DWI or UnderageDrinking ticket?
Form 564Page 3 of 5
N/A
N/A
N/A
x
x
x
Poorly worded Questions.
Only answer Yes or N/A.
Don’t leave blank
Print Name Here
Form 564Page 4 of 5
This is the page
to be notarized.Signature
Check what applies
WI Dane
Today’s Date
Print First Name Middle Initial Last Name
Medical Resident
Date of Birth (MM/DD/YYYY)
Social Security Number
X
Your UWHC email
Form 564Page 5 of 5
Items to Include
Diploma
If Applicable:
Convictions & Pending charges form
$8 check
Marriage Cert
Disregard unless you have
convictions and Pending Charges
to report
Form 2252
If you have convictions or
pending chargessuch as
alcohol violations,including
underage drinking,or
drug violationsyou must fill
out this form and attach the required
documentation.
This form must be notarized
and then include in
the DRL envelope with a $6 check.
$8Notary
DRL
Last Name First Name Your address
Social Security #
Offense Date City and State
Date of Birth
Gender &Ethnic
Sign Here Today’s Date
Form 2252Page 2 of 2
This form must be notarized
and then include in
the DRL envelope with a $8 check.
DRL
If not applicable, you may disregard.
For USMLE Step IIIFor USMLE Step IIIApplicationApplication
Check for country Check for country codes for codes for
questions 7 & 8 questions 7 & 8 on the next page on the next page
#7#7--
Country of Country of citizenshipcitizenship
#8#8--Country of Med Country of Med SchoolSchool
US code is 099US code is 099
# 7 & 8# 7 & 8
USMLE Step III
Application
Page 1 of 3
Do not Fill inDo not Fill in# 1 or 2. MEB # 1 or 2. MEB does this oncedoes this oncethey clear you they clear you
UseUseUPPERCASEUPPERCASEBlock LettersBlock Lettersand and Black InkBlack Ink
Last NameFirst Name
MM DD YY
Social Security #
099
099
United States (see code list for other countries)
Your Medical SchoolUnited States MM YYYY
Attn: Attn: IMGIMG’’ss
MM/YYYYx
Fill in your Program Name
(code list for program code)University of Wisconsin Hospital and Clinics
Madison, WIPhone #Program Director
For USMLE Step 3For USMLE Step 3ApplicationApplication
Codes for questions Codes for questions 9 & 109 & 10
on the next page on the next page
# 9# 9——GME Program GME Program CodeCode
#10#10——Specialty CodeSpecialty Code
USMLE Step III
ApplicationPage 2 of 3
Response Optional
Print Name
## Fill in your Specialty (check code list for specialty codes)
0-000-000-00-000-000-0
Home Mailing Address
City
USA
State
099Zip Code Coordinator’s Phone number
Your Email Address
Print full name on back of
photo before gluing
USMLE number!0-
000-
000-
0
Last Name
First Name
Middle Name
SS # MM/DD/YY
Wisconsin
Signature
WI Dane
USMLE Step 3ApplicationPage 3 of 3
Provide your USMLE number
Paste your2”
X 2”Photoin space provided
This form mustbe notarized
If applicable attach name change
documentation
Include inthe small
manila envelope
DRL
Form S3-08-WI
Complete form and turn
into the GME Staff
A check for $705 for Step 3 will be
required by you in Spring 2010 –
Once yourUSMLE applicationhas been sent to
the FSMB by the DRL,the GME Office will
notify you to bring the check
to GME Office so it can be includedwith this Fee Form.
Step 3 applicationsare normally sentthe first week of
May if all licensingrequirements
are met.
$705$705
Last name First name Middle name mm/dd/yyyy
000-00-0000
Medical School Name MD or DO
Graduation Date
0-
000-
000-
0
Home Address
City, State, Zip code Email Address
Apartment Number
Home phone number
Last Name
EBAHRPage 1 of 2
Fill this out if you have
passedUSMLE Step III
OR areapplying totake exam
in WisconsinONLY
Ignore if you will be using
COMLEX for licensing
First and Middle Name
Alternate/Previous Name (if applicable)
Home AddressCity State Zip
Phoneemail
SSN#United States
Medical School Name, City & CountryGrad Date (MM YYYY)
Attn:
Attn:
IMGsIMGs
USMLE #Date of Birth MM/DD/YYYY
50
50
X
Wisconsin Medical Examining Board1400 E. Washington Ave. PO Box 8935Madison WI 53708-8935
Since your $50 covers two reports, you might want
to have the second one sent to you.
(608) 266-2112
Signature Date
WI Dane
EBAHRPage 2 of 2
Make $50 check payable
to Federation
of State Medical Boards
This form must be notarized
It goes to the FSMB
EBAHRPage 2 of 2
Include a $50 check payable
to Federation
of State Medical Boards
This form must be notarized
Include inthe FSMBenvelope
FSMB●
Licensing Session
Your user name and password
to take WIStatutes Exam
Wisconsin Statutes and Rules Examination
Open book exam is taken online. You can stop and start the exam as often as you like. It will take up to 2-6 hours to complete.
20% of residents will fail the first time. Take your time.
If you fail the WI exam, you will need to pay $57 to have the exam reset.
Licensing Session
Send in fee form and checkfor $690
Must show you passed prior to USMLE
Application being processed
•For residents who are taking Step III out of state or have already passed Step III,you will need to do the AMA profile.
Cost:
Free for AMA Members $31 for Non-AMA Members
Google: AMA Profile Service.
This will take you directly to the
log-in page.
COMLEX Part 3 for Osteopaths
If you are applying to take COMLEX Part 3 you must followthe directions at http://www.nbome.org to register online
How to monitor your license application progress
We recommend that you check the DRL website weekly to see if they are missing things you think you’ve already sent in --although it may take them 2-3 weeks to update the websitehttp://drl.wi.gov/index.htm
Licensing Session
MEB small manila envelopeApplication for Full License (Form 570)
Diploma and $147 or $132 check
Work History (Form 1934)Malpractice Suits or Claims form NA (Form 2829)Hospital Verification if NA (Form 2167)Authorization and Waiver (w/ notarized signature - Form 571)
USMLE Step 3 Application (w/ notarized photo) (Step III Application)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Convictions and Pending Charges only if applicable (Form 2252)
Licensing Session