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

2. 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

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

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

5. 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.

6. 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.

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

8. 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.

9. 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.

10. 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 and another 2-4 days for your electronic exam permit to arrive via . 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.

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

12. 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,
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.

13. 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.

14. Licensing Session
Scheduling COMLEX Level 3 Exam - 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 Locate COMLEX-USA test dates

15. 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
Mary Newton-Kellogg for an application

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

17. 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

19. 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 /20?? – 6/20??
UWHC 600 Highland Avenue Madison, WI /201? - present
Attention IMGs

20. 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?

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.
Select one
Signature
Current Date WI
Dane
Print Name Here

23. Your UWHC email Form 570 Page 6 of 6 The DSPS will contact you by
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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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

31. 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

32. 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

33. 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

34. Licensing Session Request for transcripts for USMLE from FSMB
Steps 1 and 2 CK/CS for MDs or DOs
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.

35. 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

36. Licensing
For COMLEX transcripts: go to Order online Send to WI Licensing Board

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

38. 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.

39. 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?

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 This page must be notarized.
Select one
Signature
Current Date WI
Dane
Print Name Here

42. 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

43. 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

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

45. 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.

46. Licensing Session
>Enter your last name
>Select Profession

47. 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.

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

49. 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.

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

51. 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, NPDB completed following passage of Step 3
March 1, 2014 – Completion of full licensure and DEA is ordered.

52. Licensing Session Any questions contact Cindy Feuling
GME Office H4/831