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