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2014 New Hire Full Medical License and Temporary Educational Permit Licensing Instructions


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Title: 2014 New Hire Full Medical License and Temporary Educational Permit Licensing Instructions

2014 New Hire Full Medical License and
Temporary Educational Permit Licensing
  • This presentation is intended for incoming
    upper-level residents who are not licensed or
    only have their Temporary Educational Permits.

  • PG-1 with Prior GME and PG-2s Complete the
    Temporary Educational Permit and Full License
  • 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

  • Go to the Wisconsin Department of Safety and
    Professional Services website http//dsps.wi.gov/H
  • Select Application Forms
  • Select Health Professionals
  • Select Physician
  • Select Licenses/Permits/Registrations/Application
  • 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.

  • Documents to gather
  • Is your name correct on all your documentation?
  • 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
  • Federation of State Medical Boards USMLE Step

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
  • Residents are responsible for all other licensure
    and examination fees.

  • 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 Cindy Feuling, cfeuling2_at_uwhealth.org.

  • PG-1s with Prior GME
  • and PG-2s
  • How and when
  • to apply for Step 3

  • 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.

  • Why you need to register by June 15, 2014
  • Restructuring of Step 3
  • 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

  • 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
  • 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

  • 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
    drivers license.

  • DOs 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.

  • 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.

  • Full Licensure Application for License to
    Practice Medicine and Surgery

  • If you previously held a State of Wisconsin
    Medical License and it has lapsed, apply as a
  • PG-2 Wisconsin Licensing
  • PG-3 and above Wisconsin licensing

  • Form 570
  • Page 1 of 6
  • 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.

Last Name
First Name
Street Address, City State Zip
Medical School City, State
Program Specialty
MD or DO
Program Specialty Code from next page
MS Grad Date
(No Transcript)
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
Grad Date
Your Medical School Address
Grad Date
Do not leave any gaps
Grad Date 6/20XX
Prior GME Institution
Start Date 6/20XX
UWHC 600 Highland Avenue Madison, WI 53792
6/20XX - present
Attention IMGs
Form 570 Page 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
privileges in the last 5 years e.g.
moonlighting. Do not list if you were only there
as a trainee Researcher / Nurse / Pharmacist
If youve been licensed before i.e. Nurse or
Failed Exam? Provide an explanation
Conviction for DWI, disorderly conduct ,
underage drinking?
Form 570 Page 4 of 6
Questions 15-16-17 are poorly worded answer
Yes or N/A (instead of No)
  • Form 564
  • Page 5 of 6
  • Needs to be notarized.
  • Do NOT complete until you are
  • in front of a notary!

Select one
Current Date
Print Name Here
  • Form 570
  • Page 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
Your current email
  • Form 571
  • This form must be notarized,
  • original is included with
  • full application.
  • Do NOT complete until you are
  • in front of a notary!
  • ?DSPS Envelope

Place of Birth
Date of Birth
Your Signature
Print Name
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
Social Security
Date of Birth
Medical School Name
MM/DD/YYYY Date of Graduation
ECFMG if applicable
MM/DD/YYYY todays date
Physicians Signature
Ignore this. These are directions for the FSMB.
  • Form 2164
  • White Envelope addressed
  • to your Medical School

Your Name
Medical School Name
Medical School Address
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
Street, City, State, Zip
Current Date
Maiden/Given Surname
Program - Resident
University of WI Hosp Cls
600 Highland Ave Madison WI 53792
Prog Director
Previous GME Info
  • 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 2252
  • Page 1 of 2
  • 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.
  • This form will need to be notarized
  • and include an 8 check payable

Disregard unless you have convictions and pending
charges to report
Last Name
First Name
Home Address, City, State Zip
Date of Birth
Social Security
City and State
  • Form 2252
  • Page 2 of 2
  • ?DSPS Envelope

Signature if applicable
Todays Date
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
First Name MI Last Name
Home Address
  • Documents submitted in the DSPS envelope
  • Form 570 Application to Practice Medicine
    Surgery (include in envelope after being
  • 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
  • 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

  • Additional reports to be completed
  • Prior 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
  • After passing Step 3 or COMLEX complete the NPDB
    (National Practitioner Data Bank) Self-Query
    8.00 fee credit card

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 copies

  • DOs Only - After passing COMLEX
  • Request official transcript
  • For NBOME transcripts go to http//www.nbome.org/
  • 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
  • Have it sent to the WI licensing board.

  • Temporary Educational Permit (TEP)
  • If a PG-2 you must have a medical license by your
    clinical start date 6/24 or 7/1

  • Form 564
  • Page 1of 5
  • Include check for 10 made
  • out to Dept of Safety
  • Professional Services
  • Return to
  • 600 Highland Ave
  • Madison, WI 53792-8320
  • The GME Office adds an
  • Affidavit.

Print Last Name
First Name
Home Address City, State, Zip
Phone Number
Your Medical School
City, State, Country
MD or DO
Vacation/Relocation 5/20XX 6/20XX
Do not leave any gaps
University of Wisconsin Hospital Madison WI
6/20XX present
Form 564 Page 2 of 5
Failed Exam? Provide an explanation
Conviction? DWI or Underage Drinking ticket?
  • Form 564
  • Page 3 of 5

Questions 14-15-16 are poorly worded. Only
answer Yes or N/A.
  • Form 564
  • Page 4 of 5
  • Do NOT complete until you are
  • in front of a notary!

Select one
Current Date
Print Name Here
  • Form 564
  • Page 5 of 5
  • Items to Include
  • Diploma, and translation if
  • applicable
  • If Applicable
  • ECFMG certificate,
  • Convictions Pending
  • charges form
  • Name change documentation

First Name Middle Initial Last Name
Medical Resident
Social Security Number
Your current email
  • Form 2252
  • Page 1 of 2
  • 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.
  • Include an 8 check payable
  • to Safety Professional Services
  • ?DSPS envelope

Disregard unless you have Convictions and Pending
Charges to report
Last Name
First Name
Home address
Social Security Number
Date of Birth
Gender Ethnic
City and State
Form 2252 Page 2 of 2
Todays Date
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/IndividualC

How to check your status!
gtEnter your last name gtSelect Profession Medicine
Surgery MD (20) Medicine Surgery DO (21)
  • 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/IndividualC

As you see by the title Requirements not met
these items need to be addressed.
Therequirements are in red in the left column.
User name and password located on your
application status page.
These are Requirements Met, they are in green on
the left column.
Licensing Session
  • 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

  • Cindy Feuling
  • GME Office H4/831
  • 608-263-8023
  • cfeuling2_at_uwhealth.org
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