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1
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Go to http://drl.wi.gov
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Comments
Wisconsin Department of Regulation and Licensing.
Action
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Click on Health Professions (TAB MARKER);
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Go to "Physician –License to Practice Medicine...";
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Click on "Forms" (left navigation menu);
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Click on "MD/DO Needing to take step 3 of USMLE Application Packet" or if Step 3 has already been taken; choose "MD/DO by Endorsement/Reciprocity Application Packet";
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Print form 2636 (only if you need to take Step 3).
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2
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Form 2636
(Application Packet Addendum- Internet)
For USMLE Application Only
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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: Under Forms; Openbook link. The applicants now take an online exam. The link will take them to the online instructions.
Action
Print form and fax it to 608-261-7083 if you need a USMLE Step 3 application.
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3
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Form 2070
Application Information Form
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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 DRL.
Action
The DRL receives over 13,000 applications and renewals every month. It may take up to 15 days to process and post the information received.
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4
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Form 546
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Comments
IMPORTANT INFORMATION . . . Please read prior to completing Medicine and Surgery application.
Action
Reading this 5 page document will give you a very good overview of the process and answer many of your questions regarding the following topics:
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Endorsement Candidates
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USMLE Step 3 Candidates
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National Practitioner Data Bank (NPDB)
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Oral Examinations (if required)
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Codes for Specialties, Etc.
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5
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Form 2164
Medical Education Verification Form
(Not necessary if utilizing FCVS)
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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.
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6
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Form 2165
Certification of Post-Graduate Training
(Not necessary if utilizing FCVS)
Complete after passing USMLE Step 3.
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Comments
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If you have or will be completing an internship, residency, or fellowship in an accredited program you must forward this form to that Program Director.
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If you have completed training at multiple institutions, the Program Director from each institution must complete a copy of this form.
Action
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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 Medical Examining Board.
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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 Medical Examining Board will not accept them nor will they accept incomplete forms – all questions must be answered.
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If licensing is not completed in a timely manner, this form may have to be resubmitted at two month increments.
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7
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Form 2166
Employment Verification for Employers Other than Hospitals
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Comments
Action
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8
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Form 1934
Work History Medicine and Surgery
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Comments
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This form must be completed if there is a gap from graduation of medical school to completion of your residency.
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If you did research or are an International Medical Graduate who worked in your home country, you must complete this form.
Action
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9
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Form 2167
Hospital Verification- Privileges, Employment or Appointment
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Comments
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This form must be completed ONLY if you have had hospital staff privileges outside of your graduate medical education training program. (Moonlighting should be reported on the form.)
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For most PG-I's, this form will NOT be necessary. Write Not Applicable on the form.
Action
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If it does apply to your situation, a copy of this form must be sent to all hospitals that you have had staff privileges during the past 5 years.
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If it does NOT apply to your situation, return form w/application indicating "N/A".
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10
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Form 571
Authorization and Waiver
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Comments
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This is a two part form that must be completed by every applicant.
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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
Both parts of this form must be signed, dated, 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, 2166 and 2167.
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11
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AMA Physician Profile Order Form
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Comments
This form does not apply to D.O. applicants.
Effective 4/18/07, this form is NOT required by USMLE Step 3 candidates. 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. Housestaff are automatically enrolled on January 1st of their initial year with MCWAH.
Action
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Click on AMA American Medical Association Physician Profile Data https://profiles.ama-assn.org/amaprofiles/
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Click on "Profile Fee, Delivery and Accreditation Acceptance Information (e.g., JCAHO, NCQA, and AAAHC)";
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Click on "Physician Profile Order Form for Licensure Application or Renewal".
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12
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Form 1935
Request for Physician Profile Data
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Comments
This is required for D.O. applicants only.
Action
Complete and forward to the American Osteopathic Association.
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13
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Form 1445
Disciplinary Inquiries Report
(Not necessary if utilizing FCVS)
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Comments
Effective 4/18/07, this form is NOT required by USMLE Step 3 candidates. Only Endorsement 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!
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14
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Form 2252
Convictions and Pending Charges
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Comments
Relevant convictions/charges include:
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Felonies, misdemeanors or any other violations of state or federal law in any state. Pleas of no contest or guilty must be included.
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Include any convictions that involved the use of drugs and/or alcohol including convictions for "driving or operating a motor vehicle under the influence".
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Municipal violations and traffic offenses do NOT have to be included.
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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.
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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
Complete this form only if applicable.
This form must be completed and notarized along with a separate check payable to the DRL (only if applicable). See form for fee.
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15
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Form 570
Application for License to Practice
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Comments
Application Fees (fees on form): Select appropriate square; most interns and PG-2 housestaff will select "To Write Part III USMLE". (Note: This is the initial document that starts your file.)
Action
1. Complete the application;
2. It must be notarized;
3. Include check payable to "Department of Regulation and Licensing".
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16
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Form 2639
USMLE Step 3 Examination Information
USMLE Step 3 Application Form
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Comments
You will not be permitted to write the USMLE Step 3 through Wisconsin unless you are also applying for a Wisconsin license.
The entire application packet must be received in the DRL Office by August 1, 2008 to write the USMLE 2008 exam in the year 2008. After this deadline date, applicants will be required to write the USMLE 2009 exam.
Action
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Complete "2008 Step 3 Application" application form.
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Leave items 1 and 2 blank.
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Submit the Step 3 application form along with your Application for Licensure to Practice (Form 570) to the Medical Examining Board in Madison.
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Once both applications are complete and all supporting documents are received, the Medical Examining Board (MEB) sends the USMLE Step 3 Application to the Federation of State Medical Boards (FSMB).
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17
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Wisconsin USMLE Step 3 Fee Form
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Comments
The USMLE Application and supporting documents are sent to the Wisconsin Medical Examining Board in Madison, Wisconsin.
The USMLE Fee Form and check are sent to the FSMB in Dallas, Texas.
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
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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).
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Make the check or money order payable to the USMLE.
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18
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EBAHR
Examination and Board Action History Report
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Comments
EBAHR 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 the
www.nbme.org
Action
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If you have taken NBME exams you do not need to request an EBAHR; obtain your scores through www.nbme.org.
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The vast majority of the housestaff will need to request the EBAHR. An on-line transcript request may be utilized if requesting for State Medical Boards only. A hard copy must be submitted for any other purpose. Both may be found at https://secure.fsmb.org/trol/.
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$50 check (or Money Order) payable to the Federation of State Medical Boards.
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19
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NPDB
National Practitioner Data Bank
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Comments
First year US/Canadian post-graduate training candidates who have just completed their first year (no more than two months prior to application for licensure) are exempt.
All other candidates must request the Self-Query from the National Practitioner Data Bank's website www.npdb-hipdb.com.
Action
Feel free to open and review both reports, however, it is important that you send BOTH reports to the State of Wisconsin, Department of Regulation and Licensing.
For further information, please refer to Form 546.
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20
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Other Required Items
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Comments
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Copy of Professional Diploma and translation
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Copy of ECFMG Certificate (if foreign medical school graduate)
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Copies of malpractice suits. Court documents with allegations and settlement
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Legal documents pertaining to name change
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21
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Licensed in any other State?
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Action (this make 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 Medical Examining Board.
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.
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22
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Open Book Exam
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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 checksheet from DRL. 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
Go to http://drl.wi.gov/boards/med/code/codebook.htm
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.
Helpful Documents:
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23
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Oral Exam
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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.
Action
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.
For further information, please refer to Form 546.
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24
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Checking Status of License Application
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Comments
It may take up to 15 working days to process and post forms received online.
Action
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Go to http://drl.wi.gov;
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Click on Application Status on left under Licensing Information and Tools.
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Enter your last name or application number.
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25
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License Application Approved
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Comments (found on checksheet)
Once your application is complete, check the department's web site for your official credential number and grant date.
Action
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Go to http://drl.wi.gov;
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On left menu, click on Look-up License Holders.
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Under License Lookup, click on Individual Credential Search.
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Select a profession, i.e., Medicine and Surgery, MD or DO.
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Enter your last name.
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Select your last name for license information.
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