2013 - PGY-1 Full Medical and Temporary Educational Permit Licensing Session

Before the Session: Licensing Session Is your name correct on all your documentation? (i.e., diploma, USMLE scores) If not, make 3 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) 2013 Step 3 Application – Certification of Identity Envelopes: There are two envelopes in your packets – 1 manila labeled WI – Dept of Safety & Professional Services and 1 white envelope. You may require additional white envelopes depending on if you had prior GME. WI Dept of Safety & Professional Services Medical Education Verification Form Certificate of Post-Graduate training at a Non-UWHC GME training program, if applicable Hospital, Facility, & Employment Verification, if applicable

Licensing Session This session is geared toward individuals who graduated from Medical School in the spring of 2012.

Licensing Session Your Goals: To take and pass Step 3 no later than December 31, 2013 To be fully licensed by March 1, 2014

What does the hospital pay for? Licensing Session What does the hospital pay for? Licensure: The hospital will reimburse the initial license application fee ($165 To Write Step 3 or $150 Endorsement of Steps 1,2,3) upon receipt of full licensure within your PG-2 year. You are required to pay the initial license fee up front. TEP: The GME Office will submit the $10 fee to the DSPS along with the application. All other licensure and examination fees are your responsibility.

DEA Fee Licensing Session The GME Office will pay the initial and renewal fees ($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. The GME Office will apply for your DEA automatically when you are fully licensed.

How and when to apply for Step 3 Licensing Session How and when to apply for Step 3

Licensing Session There are two ways to register for USMLE Step 3 Through another state that does not require any post-graduate training nor license application. Through WI-DSPS that does require the completion of 10 months of post-graduate training and a completed license application.

Licensing Session We recommend you register through another state, such as Nebraska, Nevada, North Carolina, Louisiana, Maryland, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Virginia, West Virginia You do not have to go to that state to take the Step 3 exam You can take Step 3 sooner than if you have WI-DSPS release you. You will have a longer time within which to chose your exam window (now through December 15, 2013) You will have more control over your exam window because you can be quite sure your exam window will start within 7-14 days of when you register on-line.

Timing your Step 3 Exam Window Licensing Session Timing your Step 3 Exam Window If you register on-line at the FSMB through a “no requirement” state – it will take 7-10 days for your approval email and another 2-4 days for your electronic exam permit to arrive via email. You will have 90 days from the permit date to register and take the exam. If you register through WI, the DSPS will not release your Step 3 registration until all licensing materials are complete and you have completed 10 months of post-graduate training. Either way you must register no later than August 30, 2013 in order to take Step 3 before December 31, 2013.

Licensing Session How to register for USMLE Step 3 Access the Federation of State Medical Boards (FSMB) website (www.fsmb.org). Click on Licensure Examinations (left vertical menu) Click on Step 3 (top horizontal menu) Review Step 3 General Application Information

The Certification of Identity located on the FSMB website needs to be completed and mailed at the same time as you complete the Step 3 application at FSMB, www.fsmb.org. Indicate on this form which State licensing agency you will be taking Step 3 through. This form is required whether you are taking Step 3 through a no-requirement State or having WI-DSPS release your application.

Licensing Session Score reporting for Step 3 If you go through a no-requirement state you will not order your USMLE scores until after passing Step 3. If you go through WI-DSPS you will be required to order your USMLE Step 1, 2 CK/CS scores prior to being released to take Step 3. Your Step 3 will be directly submitted when completed.

Licensing Session Scheduling COMLEX Level 3 Exam - http://www.nbome.org/comlex-cbt Read NBOME Bulletin of Information Purchase examination Select examination to purchase Agree to terms and conditions Confirm billing payment information Schedule an examination Select location and date for examination Receive confirmation email Locate COMLEX-USA test dates

Merck Loan $1000 loan is available with a one-time $20 service fee Licensing Session Merck Loan $1000 loan is available with a one-time $20 service fee Email Mary Newton-Kellogg for an application mnewton-kellogg@uwhealth.org

Application for License to Practice Medicine and Surgery Licensing Session Application for License to Practice Medicine and Surgery

Street Address, City State Zip Code from Previous page Form 570 Page 1 of 6 MD or DO If you are applying to take USMLE Step 3 through another state Have already taken Step 3 Check the blue box Include a check for $150 DO Will be taking COMLEX 3 Check the red box Include a check for $150 If you are applying for USMLE Step 3 through Wisconsin, Check the yellow box nclude a check for $165 Make the check out to Dept of Safety & Professional Services X Last Name First Name MI Street Address, City State Zip Month Day Year Telephone Medical School City, State Program Specialty MD or DO Program Specialty Code from Previous page MS Grad Date X X X

Attention IMGs Form 570 Page 2 of 6 Do not leave gaps of more than 30 days. Enter Undergraduate Information Your Medical School Address Grad Date Do not leave any gaps Vacation/Relocation 5/20?? – 6/20?? UWHC 600 Highland Avenue Madison, WI 53792 6/201? - present Attention IMGs

Failed Exam? Form 570 Page 3 of 6 If you have been previously licensed, complete the middle section . You will also need to get documentation from that Licensing Board. Enter any institutions where you had staff privileges – e.g., moonlighting. Do not list if you were only there as a trainee If you’ve been licensed before…. Failed Exam? Conviction? DWI or underage drinking ticket?

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

Form 564 Page 5 of 6 Needs to be notarized. Select one Signature Current Date WI Dane Print Name Here

Your UWHC email 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 UWHC email

This form must be notarized, original is included with application. DSPS envelope A copy of this form should be included with: 1. Medical School Verification 2. Certificate of Post –Graduate Training , if prior GME 3. Hospital Facility and Employer verification, if applicable Name Place of Birth Date of Birth Your Signature WI Dane Print Name

Authorization and Waiver Form #571 Medical School Envelope Include a copy of Authorization and Waiver Form #571 Medical School Envelope Your Name SSN # Medical School Name Medical School Address

University of WI Hosp & Cls 600 Highland Ave Madison WI 53792 Form 1934 Beginning with your present employment at UWHC, go backwards and conclude with graduation from medical school Do not leave any gaps of more than 30 days. DSPS envelope Last First MI MM DD YY 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

Form 2167 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. Include a copy of the Authorization and Waiver Form 571 with each request. If this does not pertain to you write your name and Not Applicable at the top and include in the DSPS envelope Not Applicable First MI Last Name

Last Name Form 2252 Page 1 of 2 Read question 2 carefully Disregard unless you have convictions and Pending Charges to report Form 2252 Page 1 of 2 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 DSPS envelope If you had no convictions or charges , do not submit this form. Last Name First Name Street Address, City, State Zip Social Security # Date of Birth Offense Date City and State

Form 2252 Page 2 of 2 Must be notarized Signature Today’s Date

claim or a lawsuit pending, complete this form. 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 Name Your Address City State Zip

Licensing Session Documents submitted in the DSPS envelope Form 570 Application to Practice Medicine & Surgery (pgs1-6) with check for either $150 or $165 attached Form 571 Authorization and Waiver (original notarized) Form 1934 Work History Form 2167 Hospital Facility and Employer Verification Form 2252 Convictions and Pending Charges, submit only if applicable Form 2829 Malpractice Suits or Claims Form Diploma ECFMG certificate, if applicable Name change documentation, if applicable White envelope Form 2164 Medical Education Verification

Additional reports required for the Licensing Session Additional reports required for the State of WI – DSPS full licensure application Physician Profile Data – AMA for MDs and AOA for Dos USMLE or COMLEX Score Reports FSMB Board action inquiry transcript

Google: For MDs only Select Physicians Only – Requests for profiles to AMA Profile Service For MDs only Select Physicians Only – Requests for profiles to licensing Boards – follow the steps if through another state

Licensing Session Request for transcripts for USMLE from FSMB Steps 1 and 2 CK/CS for MDs or DOs http://www.fsmb.org/transcripts.html If you will be taking Step 3 through another state, request this transcript after passing Step 3 to include all step scores If you will have WI-DSPS release you to take Step 3, request Steps 1 and 2 (CK/CS) are required. Step 3 will automatically be sent WI-DSPS when completed.

Licensing Session The score report from FSMB will also have the Board Action Disciplinary information on it for anyone using the USMLE for Step 3. If you are taking COMLEX 3, you will also have to go the FSMB online and ask for a “transcript” that will show your Board Action Disciplinary information

Licensing For COMLEX transcripts: go to http://www.nbome.org/transcript-request.asp?m=can Order online Send to WI Licensing Board

Licensing Session Temporary Educational Permit (TEP) All PG-1’s must have a medical license by 7/1 of their PG-2 year

Form 564 Page 1of 5 Do not leave any gaps PG-1 - No check necessary. 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 5/201? – 6/201? Do not leave any gaps University of Wisconsin Hospital Madison WI 6/2012 – present PG-1 - No check necessary. the GME Office will pay this fee.

Failed Exam? Form 564 Page 2 of 5 Conviction? DWI or Underage IMG Form 564 Page 2 of 5 Failed Exam? Conviction? DWI or Underage Drinking ticket?

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

Form 564 Page 4 of 5 This page must be notarized. Select one Signature Current Date WI Dane Print Name Here

Your UWHC email Form 564 Page 5 of 5 Items to Include: Diploma 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 UWHC email

Offense Date City and State Form 2252 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 DSPS envelope If you had no convictions or charges , do not submit this form Disregard unless you have Convictions and Pending Charges to report Last Name First Name Home address Date of Birth Social Security Number Gender & Ethnic Offense Date City and State

Signature – if applicable Form 2252 Page 2 of 2 Signature – if applicable Today’s Date

How to monitor your license application progress Licensing Session How to monitor your license application progress We recommend that you check the DSPS website monthly to monitor your application status. Keep in mind it may take the DSPS 2-3 weeks to update your application status. http://dsps.wi.gov/Home

Licensing Session http://online.drl.wi.gov/ApplicationStatus/CredentialApplicationStatus.aspx >Enter your last name >Select Profession

User name and password located on your application status page. 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.

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

Wisconsin Statutes and Licensing Session 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 from 2-6 hours to complete. If you fail the exam, there is a fee to reset the exam.

After your Step 3 score has been posted on your application status page, the NPDB self query will need to be completed. Licensing Session

Timeline for Full Licensure Licensing Session Timeline for Full Licensure January 8 & 15 – Licensing session for PG-1s March 1 – All materials submitted to the DSPS April 1 – Check DSPS website to be sure you are not missing any required material April 15 – Passed online WI Statutes exam Flexible– Register and pay online for USMLE Step 3 No later than Aug 30 Flexible – Complete and mail the 2013 Step 3 Certification of Identity with picture July 1 – Your Program submits Certificate of Post Graduate training verifying completion of PG1 year and continuing PG2 year August 30 – You must register for USMLE Step 3 no later than this date because the application window for 2013 Step 3 closes February 1, 2014 - NPDB completed following passage of Step 3 March 1, 2014 – Completion of full licensure and DEA is ordered.

Licensing Session Any questions contact Cindy Feuling GME Office H4/831 263-8023 cfeuling2@uwhealth.org