Transcript New Hire Full Medical License and Temporary

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 Reregistration and/or Temporary Education Permit
–
If you already held a license with the State of Wisconsin, you must apply as a reregistration.
 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, 53708-8935
3 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 Fee
The 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
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Cindy Feuling, [email protected].
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 UWHCGME 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 3
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Registration 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
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licensed.
How to register for USMLE Step 3
Federation 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 attached
 Needs to be notarized
 Send 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 Licensing
 PG-3 and above Wisconsin licensing
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Form 570
Page 1 of 6
X
Last Name
First Name
Street Address, City State Zip
Month
Day
Year
Medical School
City, State
MD or DO
MS Grad Date
Telephone
Program Specialty
Program Specialty
Code from next page
Select which endorsement is appropriate:
MD or DO–
Endorsement of Steps 1,2,3 of USMLE
•Applying to take USMLE Step 3
through a no requirement state
•Have already taken Step 3
Check the blue box
Include a check for $150
DO – Endorsement of NBOME
Taking COMLEX 3
Check the red box
Include a check for $150
Program Specialty Code on next page.
X
X
Attach check made out to
Safety & Professional Services
Envelope addressed to:
Wisconsin Dept of Safety & Professional
Service
P.O. Box 8935
Madison, WI 53708-8935
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Form 570
Page 2 of 6
Do not leave gaps of
more than 30 days between
Medical School graduation
And starting residency.
Enter Undergraduate Information
Were you a Nurse/Pharmacist? Address
Your Medical School
Address
Grad Date
Grad Date
Vacation/Relocation
Grad Date– 6/20XX
Prior GME Institution
Start Date – 6/20XX
UWHC 600 Highland Avenue Madison, WI 53792 6/20XX - present
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Form 570
Page 3 of 6
Enter any institutions where you had staff privileges
in the last 5 years – e.g. moonlighting.
Do not list if you were only there as a trainee
Researcher / Nurse / Pharmacist
If you have been previously licensed,
complete the middle section .
You will also need to
Obtain documentation from
that Licensing Board.
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 570
Page 4 of 6
N/A
N/A
N/A
Questions 15-16-17 are
poorly worded
answer Yes or N/A
(instead of No)
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Form 564
Page 5 of 6
Needs to be notarized.
Do NOT complete until you are
in front of a notary!
Signature
WI
Current Date
Dane
Print Name Here
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Form 570
Page 6 of 6
The DSPS will contact you by
email regarding any pending
items.
First Name
Middle Initial
Last Name
Medical Resident
DSPS Envelope
Date of Birth (MM/DD/YYYY)
Social Security Number
X
Your current email
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Form 571
This form must be notarized,
original is included with
full application.
Name
Place of Birth
Date of Birth
Do NOT complete until you are
in front of a notary!
DSPS Envelope
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
First Name
MI
Last Name
Date of Birth
Medical School Name
ECFMG # if applicable
Physician’s Signature
Degree
Note! DO NOT send to DSPS
they will not process
or return the form.
Social Security #
MM/DD/YYYY
Date of Graduation
MM/DD/YYYY
todays date
Ignore this. These are
directions for the FSMB.
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Form 2164
White Envelope addressed
to your Medical School
Your Name
Medical School Name
Medical School Address
SSN #
Ignore this. These are
directions for the school.
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Form 1934
First
Last
MI
MM
DD
YY
Street, City, State, Zip
Maiden/Given Surname
Begin with your
Residency for PG1/2 or
hospital appointment
work backwards
and conclude with
graduation from
medical school
Current Date
Do not leave any gaps
of more than 30 days.
University of WI Hosp & Cls
600 Highland Ave Madison WI 53792
Program - Resident
DSPS Envelope
Prog Director
Current
Previous GME Info
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Form 2167
Not Applicable
First Name
MI
Last Name
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
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Form 2252
Page 1 of 2
Disregard
unless you have
convictions and
pending charges
to report
Last Name
If you have no convictions or
charges , do not submit this form.
Read question 2 carefully
If you have convictions or
pending charges such as
alcohol violations, including
underage drinking, or
drug violations complete
this form and attach the required
documentation.
First Name
Home Address, City, State Zip
Date of Birth
Offense
Social Security #
Date
This form will need to be notarized
and include an $8 check payable
to Safety & Professional Services.
City and State
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.
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Form 2252
Page 2 of 2
DSPS Envelope
Signature – if applicable
Today’s Date
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Form 2829
Page 1 of 2
Not Applicable
First Name MI Last Name
If not, print your name and
Not Applicable at the top.
Home Address
City
State
If you have a notice of
claim or a lawsuit pending,
complete this form.
Zip
DSPS Envelope
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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
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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 completed
Prior to taking Step 3
 AMA- MD Physician Profile Data – https://profiles.amaassn.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
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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.
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Fee $65.00 / 2 copies
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.
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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 564
Page 1of 5
Print Last Name
Home Address
MM
DD
First Name
MI
City, State, Zip
YYYY
Phone Number
Optional
Your Medical School
MM/DD/YYYY
MD or DO
Vacation/Relocation
X
City, State, Country
Program
Include check for $10 made
out to Dept of Safety
& Professional Services
Return to:
UWHC-GME
600 Highland Ave
Madison, WI 53792-8320
The GME Office adds an
Affidavit.
5/20XX – 6/20XX
University of Wisconsin Hospital Madison WI 6/20XX– present
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Form 564
Page 2 of 5
Failed Exam?
Provide an explanation
Conviction?
DWI or Underage
Drinking ticket?
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Form 564
Page 3 of 5
N/A
N/A
Questions 14-15-16 are
poorly worded. Only
answer Yes or N/A.
N/A
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Form 564
Page 4 of 5
Do NOT complete until you are
in front of a notary!
Signature
WI
Current Date
Dane
Print Name Here
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Form 564
Page 5 of 5
Items to Include:
Diploma, and translation if
applicable
First Name
Middle Initial
Last Name
Medical Resident
MM
DD
YYYY
If Applicable:
•ECFMG certificate,
•Convictions & Pending
charges form
•Name change documentation
Social Security Number
X
Your current email
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Form 2252
Page 1 of 2
Disregard unless
you have
Convictions and
Pending Charges
to report
Last Name
If you had no convictions this form
does not need to be submitted
If you have convictions or
pending charges such as
alcohol violations, including
underage drinking, or
drug violations, complete
this form and attach the required
documentation.
First Name
Home address
Date of Birth
Social Security Number
DSPS envelope
Gender &
Ethnic
Offense
Include an $8 check payable
to Safety & Professional Services
Date
City and State
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Form 2252
Page 2 of 2
Signature
Today’s Date
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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
How to check
your status!
>Enter your last name
>Select Profession:
Medicine & Surgery MD (20)
Medicine & Surgery DO (21)
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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/IndividualCredential
Search.aspx
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As you see by the title – Requirements not met these items need to be addressed.
Therequirements are in red in the left column.
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These are Requirements Met, they are in green on the left column.
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Complete 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
Licensing Session
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Cindy Feuling
GME Office H4/831
608-263-8023
[email protected]
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