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

1. 2014 New Hire Full Medical License and Temporary Educational Permit Licensing Instructions

2. This presentation is intended for incoming upper-level residents who are not licensed or only have their Temporary Educational Permits.

3. 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

4. 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 forEndorsement/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.

5. 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

6. 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.

7. 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 Cindy Feuling, cfeuling2@uwhealth.org.

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

9. 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.

10. 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 licensed.

11. 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 ano-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

12. 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.

13. 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.

14. 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.

15. Full Licensure Application for License to Practice Medicine and Surgery

16. 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

17. 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. • 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 X Last Name FirstName Street Address, City State Zip Day Month Year Telephone Medical School City, State Program Specialty MD or DO Program Specialty Code from next page MS Grad Date X X

19. 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 Vacation/Relocation Grad Date– 6/20XX Prior GME Institution Start Date – 6/20XX UWHC 600 Highland Avenue Madison, WI 53792 6/20XX - present Attention IMGs

20. 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 you’ve been licensed before – i.e. Nurse or Pharmacist Failed Exam? Provide an explanation Conviction for DWI, disorderly conduct , underage drinking?

21. Form 570 Page 4 of 6 Questions 15-16-17 are poorly worded answer Yes or N/A (instead of No) N/A N/A N/A

22. Form 564 Page 5 of 6 Needs to be notarized. Do NOT complete until you are in front of a notary! Select one Signature Current Date WI Dane Print Name Here

23. 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 X Your current email

24. 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 Name Place of Birth Date of Birth Your Signature WI Dane Print Name

25. 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 Degree Social Security # Date of Birth Medical School Name MM/DD/YYYY Date of Graduation ECFMG # if applicable MM/DD/YYYY todays date Physician’s Signature Ignore this. These are directions for the FSMB.

26. Form 2164 • White Envelope addressed to your Medical School Your Name SSN # Medical School Name Medical School Address Ignore this. These are directions for the school.

27. 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 MM DD YY Last First MI Street, City, State, Zip Maiden/Given Surname Current Date Program - Resident University of WI Hosp & Cls 600 Highland Ave Madison WI 53792 Prog Director Current Previous GME Info

28. 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

29. Disregard unless you have convictions and pending charges to report 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 to Safety & Professional Services. 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. Last Name First Name Home Address, City, State Zip Date of Birth Social Security # Offense Date City and State

30. Form 2252 Page 2 of 2 DSPS Envelope Signature – if applicable Today’s Date

31. 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 City State Zip

32. 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 • FSMB – Disciplinary Inquiry Report • Form 2164 Medical Education Verification addressed to Medical School • If prior GME – Certificate of Post-Graduate Training address envelope

33. 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 DataNo 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

34. 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

35. 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

36. 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.

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

38. Form 564 Page 1of 5 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. Print Last Name First Name MI Home Address City, State, Zip MM DD YYYY Phone Number Optional X Your Medical School City, State, Country MM/DD/YYYY MD or DO Program Vacation/Relocation 5/20XX – 6/20XX Do not leave any gaps University of Wisconsin Hospital Madison WI 6/20XX– present

39. Form 564 Page 2 of 5 IMG Failed Exam? Provide an explanation Conviction? DWI or Underage Drinking ticket?

40. Form 564 Page 3 of 5 Questions 14-15-16 are poorly worded. Only answer Yes or N/A. N/A N/A N/A

41. Form 564 Page 4 of 5 Do NOT complete until you are in front of a notary! Select one Signature Current Date WI Dane Print Name Here

42. 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 MM DD YYYY Social Security Number X Your current email

43. 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 First Name Last Name Home address Date of Birth Social Security Number Gender & Ethnic Offense City and State Date

44. Form 2252 Page 2 of 2 Signature Today’s Date

45. 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

46. http://online.drl.wi.gov/ApplicationStatus/CredentialApplicationStatus.aspxhttp://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)

47. 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/IndividualCredentialSearch.aspx

48. 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.

49. These are Requirements Met, they are in green on the left column.

50. 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