Graduate Medical Education

1

Go to http://drl.wi.gov

Comments

Wisconsin Department of Safety and Professional Services (DSPS).

Action

1. Click on the "Choose Profession" link located directly under the "All Professions" heading;
2. Go to "Physician";
3. Click on "Applications / Forms" under Licensing;
4. Scroll down to "Application Packet (Step 3 USMLE)" if you plan on taking Step 3 through the State of WI or if Step 3 has already been taken or will be taken through a State other than WI, choose "Application Packet (Endorse/Reciprocity)"; or "Application Packet" (Minnesota licenses) if you hold a current Minnesota license
5. Review comments below specific forms and print. 

2

Form 546

Comments

IMPORTANT INFORMATION . . . Please read prior to completing Medicine and Surgery application. 

Action

Reading this 7-page document will give you a very good overview of the process and answer many of your questions regarding the following topics:

• Endorsement Candidates
• USMLE Step 3 Candidates
• National Practitioner Data Bank (NPDB)
• Oral Examinations (if required)
• Codes for Specialties, Etc.

3

Form 570

Application for License to Practice

Comments

Application Fees (fees on form):  Select appropriate square; most interns and PG-2 housestaff will select "To Write Part III USMLE".  

(NOTE: Form 570 is the initial document that starts your file and initiates an online checklist.)

Action

    1.   Complete the application;

    2.   It must be notarized;

    3.   Include check payable to "Department of Safety & Professional Services".

4

Form 571

Authorization and Waiver

Comments

• This form must be completed by every applicant.
• This form authorizes any and all parties to provide information about your professional background and fitness to practice medicine.  It also authorizes any and all parties to provide information about any past charges or complaints filed against you.

Action

This form must be signed in the presence of a Notary Public and notarized.

As recommended by the MEB, a copy of this form should accompany various requests for information to avoid delays, i.e. Forms 2164 and 2167.

5

Form 1445

Disciplinary Inquiries Report

(Not necessary if utilizing FCVS)

Comments

This form is NOT required by housestaff who will be taking USMLE Step 3 through the State of Wisconsin.  Only "Endorse/Reciprocity" candidates must comply.

The State of Wisconsin requires a disciplinary search by the Federation of State Medical Examining Boards on each candidate for licensure.

Action

This form must be completed and mailed to the Federation of State Medical Boards in Texas.

No charge for this one!

6

Form 1934

Work History Medicine and Surgery

Comments

• This form must be completed if:  1) there is a gap from graduation of medical school to completion of your residency. or 2) you did research or are an International Medical Graduate who worked in your home country.

Action

• If you are a PG-I or went from medical school to training, complete only Section A.

7

Form 1935

Request for Physician Profile Data

Comments

This is required for D.O. applicants only.

Action

Complete and forward to the American Osteopathic Association.

8

Form 1988

Notices

Comments

IMPORTANT INFORMATION . . . PLEASE READ.  Contains important information regarding application denial, change of address, use and availability of personally identifiable information, etc.

9

Form 2070

Application Information Form

Comments

IMPORTANT INFORMATION . . . Please read prior to completing application paperwork!!!  A description of how to track your licensure application progress.  It is the applicant's obligation to see that items listed as "Is Required" are forwarded to the DSPS.

Action

The DSPS receives over 13,000 applications and renewals every month.  It may take up to 20 working days to process and post the information received.

10

Form 2164

Medical Education Verification Form

(Not necessary if utilizing FCVS)

Comments

This form may take the longest to have completed and returned!!

Action

Must be sent to your medical school (including international medical schools).

Your medical school must complete and return directly to the State of Wisconsin.

11

Form 2165

Certification of Post-Graduate Training

(Not necessary if utilizing FCVS)

Complete after passing USMLE Step 3.

Comments

• This form should be completed AFTER USMLE Step 3 has been passed.
• If you have or will be completing an internship, residency or fellowship, you must forward this form to each Program Director.
• If you have completed training at multiple institutions, the Program Director from each institution must complete a copy of this form.

Action

• If you are a MCWAH housestaff, after the form is completed and signed, it must be forwarded to the MCWAH Office to have the seal affixed.  MCWAH will track and forward the form directly to the DSPS.
• If you are in your first year of training, Program Directors must not sign or date this form prior to you passing STEP 3 and completion of PG-I year.  The DSPS will not accept them nor will they accept incomplete forms – all questions must be answered.
• If licensing is not completed in a timely manner, this form may have to be resubmitted at two month increments.

12

Form 2167

Hospital, Facility and Employer Verification

Comments

• This form must be completed ONLY if you have had employment or hospital staff privileges outside of your graduate medical education training program.  (Moonlighting should be reported on the form.)
• For those in their first year of GME, this form will NOT be necessary. 

Action

• If it does apply to your situation, a copy of this form must be sent to all employers or hospitals that you have had staff privileges during the past 5 years.  Overseas activities need not be listed on this form.
• If it does NOT apply to your situation, there is no need to submit this form.

13

Form 2252

Convictions and Pending Charges

Comments

Complete this form only if applicable.

Relevant convictions/charges include:

• Felonies, misdemeanors or any other violations of state or federal law in any state.  Pleas of no contest or guilty must be included.
• Include any convictions that involved the use of drugs and/or alcohol including convictions for "driving or operating a motor vehicle under the influence".
• Municipal violations and traffic offenses do NOT have to be included.
• You must provide certified copies of police reports, criminal complaint, judgment of conviction and sentencing, and verification of your compliance with all terms of each sentence, including chemical dependency assessments if ordered by the court.
• If records have been destroyed, you must provide a written description of each offense, explanation of the penalties and verification of compliance and completion.

Action

This form must be completed and notarized along with a separate check payable to the DSPS (only if applicable).  See form for fee.

14

Form 2636

(Application Packet Addendum- Internet)

For USMLE Application Only

Comments

D.O. applicants are handled as reciprocity candidates and it is their responsibility to pursue COMLEX separately.

This is required to receive the USMLE Step 3 application packet.

NOTE:The applicants now take an online exam (See instructions at http://drl.wi.gov/profdetail.asp?pdetailid=2419&profid=33&locid=0and comments section on your online checklist for password information) 

Action

Print form and fax it to 608-261-7083 if you need a USMLE Step 3 application.

15

Form 2829

Malpractice Suits or Claims Form

Comments

Complete this form only if applicable. 

• This form is self-explanatory.  Please follow instructions in Section B of form. 
• This form must be signed in the presence of a Notary Public.

16

AMA Physician Profile Order Form

Comments

This form does not apply to D.O. applicants.

This form is NOT required by housestaff who will be taking USMLE Step 3 through the State of WI.  Only "Endorsement" candidates with an MD degree must comply and send directly to the AMA Office.  It can also be done on-line.  

There is a fee for this service, payable by check or charge card, if you are not a member of the AMA.  MCWAH Housestaff are automatically enrolled on January 1st of their initial year. 

Action

• Click on AMA  American Medical Association Physician Profile Data https://profiles.ama-assn.org/amaprofiles.
• Click on "Profile Fee, Delivery and Accreditation Acceptance Information (e.g., JCAHO, NCQA and AAAHC)";
• Click on "Physician Profile Order Form for Licensure Application or Renewal".

17

USMLE Step 3 Examination Information

USMLE Step 3 Application Form

Comments

You will not be permitted to write the USMLE Step 3 through Wisconsin unless you are also applying for a Wisconsin license.  You will need to submit Form 2636 to the State of Wisconsin to receive this information.
 

The entire application packet must be received in the DSPS Office by August 1, 2012 to write the USMLE 2012 exam in the year 2012.  After this deadline date, applicants will be required to write the USMLE 2013 exam.

Action

1. Complete "2012 Step 3 Application" application form.
2. Leave items 1 and 2 blank.
3. Submit the Step 3 application form along with your Application for Licensure to Practice (Form 570) to the DSPS in Madison. 
4. Once both applications are complete and all supporting documents are received, the Department of Safety and Professional Services (DSPS) sends the USMLE Step 3 Application to the Federation of State Medical Boards (FSMB).

18

Wisconsin USMLE Step 3 Fee Form

Comments

The USMLE Application and supporting documents are sent to the Wisconsin Dept of Safety & Professional Services (DSPS) in Madison, Wisconsin.

The USMLE Fee Form and check or money order (payable to the USMLE) are sent to the FSMB in Dallas, Texas.  Wait until your licensure process is well underway before mailing payment.
 

• An individual can delay submitting this form with payment until a majority of his/her Licensure and USMLE Step 3 application requirements have been met. 

Action

• The FSMB will not authorize you to schedule Step 3 until they receive this form with payment (personal check, cashier's check or money order).

19

EBAHR

Examination and Board Action History Report

Comments

The FSMB will certify a complete history of your licensure exams (USMLE or FLEX) and any action taken against you and reported to the FSMB by a licensing or disciplinary board and/or credentialing agency.

The FSMB has no access to National Board scores.  Applicants needing those scores will need to contact either the www.nbme.orgor www.nbome.org.

Action

• If you have taken NBME or NBOME exams, you do not need to request an EBAHR; obtain your scores through www.nbme.orgor www.nbome.org.
• The vast majority of the housestaff will need to request the EBAHR.  An on-line transcript request may be utilized if requesting for any State Medical Board.  A hard copy must be submitted for any other purpose.  Both may be found at https://secure.fsmb.org/trol/. 
• Payment in the form of a check or Money Order payable to the Federation of State Medical Boards is acceptable for hard copy submissions.

20

NPDB

National Practitioner Data Bank

Comments

All housestaff (MDs and DOs) must request the Self-Query from the National Practitioner Data Bank's website http://www.npdb-hipdb.hrsa.gov/pract/hasAReportBeenFiledOnYou.jsp  after USMLE Step 3 has been passed and after you have completed 12 months of GME in the United States or Canada.

Action

On the NPDB homepage, under "Practitioners", click on "Has a Report Been Filed on You?"  Then, click on "Search on Myself" and refer to "Helpful Hints for Submitting a Self-Query". 

This is a self-query, therefore, the results will be mailed and/or emailed to you.  Review the report to make sure that the results were not rejected and all information submitted is correct.  Forward all parts of the report directly to the State of Wisconsin, Department of Safety and Professional Services (DSPS). 

If you receive a rejection notice, follow the accompanying instructions.

For further information, please refer to Form 546 (page 3).

21

Other Required Items

Comments

• Photocopy of Professional Diploma (with English Translation, if applicable)
• Photocopy of ECFMG Certificate (if foreign medical school graduate)
• Photocopies of Malpractice Suits (court documents with allegations and settlement if under 10 years)
• Legal Documents Pertaining to Name Change (photocopy acceptable)

22

Licensed in any other State?

Action (this may take additional review time)

You are required to have each State Board in which you have ever been licensed submit letters of verification to the Wisconsin Dept of Safety and Professional Services.

Contact each Board you held or hold a license to see if a fee is required.

The letters must indicate your date of birth, License Number, Date of Issuance and a statement regarding disciplinary actions.  These letters will be required in order to complete your application for licensure. 

MINNESOTA LICENSES - Housestaff with a current license in the State of Minnesota now have a shortened WI licensure application process.  (See forms specific to Minnesota licensees at http://drl.wi.gov/prof_docs_list.asp?profid=33&locid=0)

23

Open Book Exam

Comments

The open book exam is now taken on-line.  (Note: You may view but not access until you have your ID #.)  You will receive information to access this exam when you receive your checklist from DSPS.  There are numerous versions of this test.  A score of 90% is required to pass the test.  A separate fee will be charged for scoring a second or subsequent test.

Action

To view the code book, go to http://drl.wi.gov/board_code_detail.asp?boardid=35&locid=0.

Scroll through the "Excerpts from the Wisconsin Statutes" and "Excerpts from the Wisconsin Administrative Code"to respond to questions that you are uncertain of.  Keep in mind that a 90% grade is required for passing. 

(To take open book exam on the Wisconsin Statutes and Administrative Code, go to http://drl.wi.gov/profdetail.asp?pdetailid=2419&profid=33&locid=0.) 

Helpful Documents found on the forms page under "Other Information/Forms":

• Form 2147 - Physician Requirements and Guidelines
• Form 2450 - The Amphetamine Rule (Chapter Med 10)

24

Oral Exam

Comments

Few applicants are required to take an Oral Exam. Substance abuse, disciplinary actions, convictions of crimes, denial of a license in Wisconsin or another jurisdiction, loss of hospital privileges, and individual graduates from a medical school not approved by the Board are possible reasons for an Oral Exam to be administered.  An applicant can also be required to take an oral exam if the applicant has taken a licensure exam four or more times before achieving a passing grade.

Action

All oral exams will be administered when the Medical Examining Board meets.  Available dates will be provided by the State of Wisconsin.

For further information, please refer to Form 546.

25

Checking Status of License Application

Comments

It may take up to 20 working days to process and to post the forms that have been received online.  

Action

1. Go to http://online.drl.wi.gov/ApplicationStatus/CredentialApplicationStatus.aspx;
2. Enter your last name (first name optional) or application number. 

26

License Application Approved

Comments (Found on Checksheet)

Once your application is complete, check the department's web site for your official credential number and grant date.

Action

1. Go to http://online.drl.wi.gov/LicenseLookup/IndividualCredentialSearch.aspx.
2. Select “Medicine & Surgery, MD” or Medicine & Surgery, DO”
3. Enter your last name.
4. Select your last name for license information.