2014 New Hire
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This presentation is intended for incoming upper-level residents who are not licensed or only have their Temporary Educational
Permits.
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
– Read through entire PowerPoint

or if you already possess your TEP
– Slides 14-35
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 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 for Endorsement/Reciprocity or Reregistration and/or Temporary Education Permit
– If you already held a license with the State of Wisconsin, you must apply as a reregistration.
 Print each of the forms listed.
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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
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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.
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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.
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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.
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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. 10

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 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
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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.
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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.
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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.
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


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X
Last Name
X
Month
Day Year
First Name
Street Address, City State Zip
Telephone
Medical School
City, State
MD or DO
MS Grad Date
Program Specialty
Program Specialty
Code from next page
X
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
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18

Enter Undergraduate Information
Were you a Nurse/Pharmacist? Address Grad Date
Your Medical School Address Grad Date
Vacation/Relocation Grad Date
– 6/20XX
Prior GME Institution Start Date
– 6/20XX
UWHC 600 Highland Avenue Madison, WI 53792 6/20XX - present
Form 570
Page 2 of 6
Do not leave gaps of more than 30 days between
Medical School graduation
And starting residency.
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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
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.
Failed Exam?
Provide an explanation
Conviction for DWI, disorderly conduct , underage drinking?
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Form 570
Page 4 of 6
N/A
N/A
N/A
Questions 15-16-17 are poorly worded answer Yes or N/A
(instead of No)
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WI
Signature
Dane
Current Date
Print Name Here
Form 564
Page 5 of 6
Needs to be notarized.
Do NOT complete until you are in front of a notary!
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First Name Middle Initial Last Name
Medical Resident
Date of Birth (MM/DD/YYYY)
Social Security Number
X
Your current email
Form 570
Page 6 of 6
The DSPS will contact you by email regarding any pending items.
 DSPS Envelope
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Name Place of Birth Date of Birth
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
WI
Your Signature
Dane
Print Name
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First Name MI Last Name
Date of Birth
Medical School Name
ECFMG # if applicable
Physician’s Signature
Degree
Social Security #
MM/DD/YYYY
Date of Graduation
MM/DD/YYYY todays date
Ignore this. These are directions for the FSMB.
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.
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Your Name
Medical School Name
Medical School Address
SSN #
Form 2164
 White Envelope addressed to your Medical School
Ignore this. These are directions for the school .
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MM DD YY
Last
Maiden/Given Surname
First MI
Street, City, State, Zip
Current Date
Program - Resident University of WI Hosp & Cls
600 Highland Ave Madison WI 53792
Prog Director
Current
Previous GME Info
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
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Not Applicable
First Name MI Last Name
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
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Disregard unless you have convictions and pending charges to report
Last Name
First Name
Home Address, City, State Zip
Date of Birth
Social Security #
Offense
Date
City and State
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.
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Form 2252
Page 2 of 2

DSPS Envelope
Signature – if applicable Today’s Date
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City
First Name MI Last Name
Home Address
State
Not Applicable
Zip
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
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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
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Additional reports to be completed
Prior to taking Step 3
 AMA- MD Physician Profile Data – https://profiles.amaassn.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 fee
After passing Step 3 or COMLEX complete the NPDB (National
Practitioner Data Bank) Self-Query $8.00 fee credit card
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Select this one
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
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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.
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Fee $65.00 / 2 copies

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.
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Print Last Name
Home Address
First Name MI
City, State, Zip
MM
Optional
DD YYYY
Phone Number
Your Medical School
MM/DD/YYYY MD or DO
X
City, State, Country
Program
Vacation/Relocation 5/20XX
– 6/20XX
University of Wisconsin Hospital Madison WI 6/20XX – present
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.
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Form 564
Page 2 of 5
Failed Exam?
Provide an explanation
Conviction?
DWI or Underage
Drinking ticket?
39

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

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

First Name Middle Initial Last Name
Medical Resident
MM DD YYYY
Social Security Number
X
Your current email
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
42

Disregard unless you have
Convictions and
Pending Charges to report
Last Name
Date of Birth
First Name
Home address
Social Security Number
Gender &
Ethnic
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
Offense Date City and State
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Form 2252
Page 2 of 2
Signature Today’s Date
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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
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http://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)
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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/IndividualCredential
Search.aspx
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As you see by the title – Requirements not met these items need to be addressed.
Therequirements are in red in the left column.
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These are Requirements Met , they are in green on the left column.
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Complete the NPDB self query after your USMLE/COMLEX scores have been
page.
Directions available in Med Hub /
GME Resources / Licensing
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Cindy Feuling
GME Office H4/831
608-263-8023 cfeuling2@uwhealth.org
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