Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935
FAX #:
Phone #:
Madison, WI 53708-8935
(608) 261-7083
(608) 266-2112
1400 E. Washington Avenue
Madison, WI 53703
E-Mail: dsps@wisconsin.gov
Website: http://dsps.wi.gov
MEDICAL EXAMINING BOARD
INFORMATION FOR COMPLETING THE APPLICATION FOR A RESIDENT EDUCATIONAL LICENSE
PLEASE PLAN AHEAD:
Applicants, recruiters, institutions, and others involved in the placement of individuals who seek to be credentialed in the state of Wisconsin
should understand that the credentialing process takes time and that credentialing is not guaranteed to any applicant. Factors that determine
the length of time it may take to process an application include the length of time the applicant has been in practice, the total number of
jurisdictions in which the applicant has been credentialed, and the length of time it takes for supporting documents to be received in the Board
office and reviewed.
The application consists of an all-inclusive packet with instructions and information on all applicable requirements. We strive to process
applications in a timely fashion. We cannot issue a credential until all of the required documents have been received and reviewed in the
Board office.
It is the Departments mission and legislative mandate to provide consumer protection for Wisconsin residents. The Department and the
Board have been asked to waive requirements to expedite the process, only to discover legitimate grounds to deny a credential. This can
present a serious problem for the applicant, recruiter or institutions if the applicant has relocated, purchased property, or made other
commitments prior to the issuance of a Wisconsin credential. We urge you not to make these moves until you know that your credential
has been issued. Please plan ahead as we cannot speed up the credentialing process or waive supporting documents even in emergency
situations.
This license is designed for an applicant who has been accepted into a post-graduate training program in a facility in this state
approved by the board under the provisions of Wis. Admin. Code Med 5.02.
AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
Completed application form and fee (Form #564)
Certificate of Professional Education (Form #3050)
Affidavit of Hospital Authority (Form #2601)
MAILING INSTRUCTIONS: Mail the Application for Licensure, the appropriate fee, and documentation to the following address:
MAILING ADDRESS:
DSPS
ATTN: MEDICAL EXAMINING BOARD
P.O. BOX 8935
MADISON WI 53708-8935
EXPRESS DELIVERY:
DSPS
ATTN: MEDICAL EXAMINING BOARD
1400 E. WASHINGTON AVE
MADISON WI 53703
#564 (Rev. 3/15)
Ch. 488, Stats.
i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
CODES FOR SPECIALTIES: Enter specialty code(s) on page 1 of the Application.
Academic Medicine
Administrative Medicine
Aerospace Medicine
Alcoholism - Chemical Dependency
Allergy - Immunology
Anesthesiology
Aviation Medicine
Dermatology
Emergency Medicine
Endocrinology
Family Medicine
Gastroenterology
General Practice
Genetics
Geriatrics
Hand Surgery
Hebiatrics
Hematology
Hyperbaric Medicine
Immunology - Infectious Diseases
Institutional Medicine
Internal Medicine
Internal Medicine - Cardiology
Internal Medicine - Pulmonary Medicine
Neonatology
Nephrology
Neurology
Neuromuscular Medicine
Neurophysiology
Nuclear Medicine
Obstetrics and Gynecology
Occupational Medicine
Oncology
Ophthalmology
Orthopedic Surgery
37
71
33
49
01
02
32
03
31
56
925
06
08
61
29
64
46
07
65
47
39
04
05
45
63
40
10
926
51
23
12
30
38
13
14
Otolaryngology
Otorhinolaryngology - ENT
Pain
Pathology
Pathology - Clinical
Pathology - Surgical Anatomic
Pediatrics
Pediatrics - Other
Perinatology
Pharmacology - Clinical
Physical Medicine and Rehabilitation
Preventive Medicine
Proctology
Psychiatry
Psychiatry - Child
Public Health
Radiation - Oncology
Radiology
Radiology - Diagnostic
Radiology - Nuclear Medicine
Radiology - Ultrasound
Research
Retired
Rheumatology
School Physician
Surgery - Cardiovascular
Surgery - Colon and Rectal
Surgery - General
Surgery - Maxillofacial
Surgery - Neurological
Surgery - Peripheral Vascular
Surgery - Plastic
Surgery - Thoracic
Urology
#564 (Rev. 3/15)
Ch. 488, Stats.
67
15
66
16
17
72
18
60
62
48
19
09
36
20
21
22
70
53
43
68
69
34
24
57
52
44
54
25
58
11
59
26
27
28
ii
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935
1400 E. Washington Avenue
Madison, WI 53703
E-Mail: dsps@wisconsin.gov
Website: http://dsps.wi.gov
Madison, WI 53708-8935
(608) 261-7083
(608) 266-2112
FAX #:
Phone #:
MEDICAL EXAMINING BOARD
APPLICATION FOR RESIDENT EDUCATIONAL LICENSE
Under Wisconsin law, the Department must deny your application if you are liable for delinquent State Taxes or Child Support (Wis. Stat. 440.12).
Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10 or
more credential holders (Wis. Stat. 440.14).
PLEASE TYPE OR PRINT IN
INK
Last Name
First Name
MI
Former / Maiden Name(s)
Address (street, city, state, zip)
Daytime Telephone Number
Mailing Address (if different)
Date of Birth
Ethnicity/gender status information is optional.
Ethnicity:
White, not of Hispanic origin
Black, not of Hispanic origin
Sex:
Your Social Security Number or Employer Identification Number must be submitted
with your application on this form. If you do not have a Social Security Number, you must complete
Form #1051. The Department may not disclose the Social Security Number collected except as
authorized by law.
Social Security #
-
American Indian or Alaskan
Hispanic
Asian or Pacific Islander
Other
Email Address:
Specialty: (see page ii for a list of codes)
Medical School:
Specialty Code:
School Address:
For Receipting Use Only (851)
Degree:
Date Degree Granted:
APPLICATION FEES: Please check box. Make check payable to DSPS and
attach to this application.
Required DSPS Fee - $10.00
#564 (Rev. 3/15)
Ch. 448, Stats.
Page 1 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
POST-GRADUATE TRAINING/FELLOWSHIPS, PRACTICE, AND OTHER ACTIVITIES: List in chronological order from the date of graduation
of medical school to the present time. Below information must include professional and nonprofessional activities. (Attach additional sheets if
necessary using the same format.)
DATES
(Month, Year)
TYPE
(From)
(To)
(From)
(To)
(From)
(To)
(From)
(To)
(From)
(To)
(From)
(To)
ECFMG Exam Taken?
Certificate #:
NAME OF SCHOOL, HOSPITAL CLINIC
OR OTHER
Post Grad
Intern
Resident
Fellow
Practice
Other
Post Grad
Intern
Resident
Fellow
Practice
Other
Post Grad
Intern
Resident
Fellow
Practice
Other
Post Grad
Intern
Resident
Fellow
Practice
Other
City)
(State)
(Country)
City)
(State)
(Country)
(City)
(State)
(Country)
City)
(State)
(Country)
Post Grad
Intern
Resident
Fellow
Practice
Other
City)
(State)
(Country)
Post Grad
Intern
Resident
Fellow
Practice
Other
Yes
No
LOCATION
(City, State and Country)
City)
(State)
(Country)
Certificate Issued?
Date Issued:
#564 (Rev. 3/15)
Ch. 448, Stats.
Yes
/
No
/
Page 2 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
ANSWER THE FOLLOWING QUESTIONS: (Attach additional sheets if necessary)
1.
Are you familiar with the state health laws and rules and regulations of the Wisconsin Department of
Health regarding communicable diseases?
Yes
No
2.
Have you ever surrendered, resigned, canceled, or been denied a professional license or other credential
in Wisconsin or any other jurisdiction? If yes, give details on an attached sheet, including the name
of the profession and the agency.
Yes
No
Yes
No
Has any licensing or other credentialing agency ever taken any disciplinary action against you, including
but not limited to any warning, reprimand, suspension, probation, limitation, or revocation? If yes,
attach a sheet providing details about the action, including the name of the credentialing agency
and date of action.
Yes
No
5.
Is disciplinary action pending against you in any jurisdiction? If yes, attach a sheet providing details
about pending action, including the name of the agency and status of action.
Yes
No
6.
Have you ever been convicted of a misdemeanor or a felony, or do you have any felony or misdemeanor
charges pending against you? If yes, submit Convictions and Pending Charges (Form #2252).
Yes
No
Are you incarcerated, on probation, or on parole for any conviction? If applicable, attach a sheet
providing details including the terms of incarceration and a copy of a report from your probation
or parole officer.
Yes
No
Have any suits or claims ever been filed against you as a result of professional services? If yes, submit
a copy of the claim or suit and a copy of the final settlement or disposition and complete
Malpractice Suits or Claims (Form #2829).
Yes
No
9.
Have your hospital privileges ever been limited or removed? If yes, give details on an attached sheet.
Yes
No
10.
Are you registered or licensed in any other profession(s)? If yes, state what profession(s) and in what
state(s):
Yes
No
Yes
No
Yes
No
3.
4.
7.
8.
11.
12.
Have you ever failed to pass any State Board, National Board (NBME or NBOME), FLEX, or USMLE
Examination? If yes, provide details below:
Have you ever been credentialed under any other name(s)? If yes, state name(s) credentialed under:
Has the Drug Enforcement Administration ever withdrawn your DEA number or warned you, or have
you been denied a DEA number? If yes, give details on an attached sheet.
For the purposes of these questions, the following phrases or words have the following meanings:
"Ability to practice medicine" is to be construed to include all of the following:
1.
The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned medical judgments and to learn and keep abreast of medical
developments; and
2.
The ability to communicate those judgments and medical information to patients and other health care providers, with or without the use of aids or devices,
such as voice amplifiers; and
3.
The physical capability to perform medical tasks such as physical examination and surgical procedures, with or without the use of aids or devices, such as
corrective lenses or hearing aids.
"Medical condition" includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing
impairments, Cerebral Palsy, Epilepsy, Muscular Dystrophy, Multiple Sclerosis, cancer, heart disease, Diabetes, mental retardation, emotional or mental illness, specific
learning disabilities, HIV disease, Tuberculosis, drug addiction, and alcoholism.
"Chemical substances" is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid prescription for legitimate medical purposes
and in accordance with the prescriber's direction, as well as those used illegally.
Currently" does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it means recently enough so that the use
of drugs may have an ongoing impact on one's functioning as a licensee, or within the past two years.
"Illegal use of controlled dangerous substances" means the use of controlled dangerous substances obtained illegally (e.g. Heroin or Cocaine) as well as the use of
controlled dangerous substances, which are not obtained pursuant to a valid prescription, or not taken in accordance with the directions of a licensed health care
practitioner.
#546 (Rev. 3/15)
Ch.448.Stats
Page 3 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
ANSWER THE FOLLOWING QUESTIONS: (Attach additional sheets if necessary)
13.
Do you have a medical condition which in any way impairs or limits your ability to practice medicine
with reasonable skill and safety? If yes, please explain.
Yes
No
14.
Does your use of chemical substances in any way impair or limit your ability to practice medicine with
reasonable skill and safety? If yes, please explain.
Yes
No
15.
Are the limitations or impairments caused by your medical condition reduced or ameliorated because you
receive ongoing treatment (with or without medications) or participate in a monitoring program? If yes,
please explain.
Yes
No
16.
Are the limitations or impairments caused by your medical condition reduced or ameliorated because of
the field of practice, the setting, or the manner in which you have chosen to practice? If yes, please
explain.
Yes
No
17.
Have you ever been diagnosed as having or have you ever been treated for Pedophilia, Exhibitionism, or
Voyeurism? If yes, please explain.
Yes
No
18.
Are you currently engaged in the illegal use of controlled dangerous substances?
Yes
No
19.
If yes, are you currently participating in a supervised rehabilitation program or professional assistance
program which monitors you in order to assure that you are not engaging in the illegal use of controlled
dangerous substances? If yes, please explain.
Yes
No
CERTIFICATION OF LEGAL STATUS:
I declare under penalty of law that I am (check one):
A citizen or national of the United States, or
A qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license or
credential as defined in the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, as codified in 8 U.S.C.
1601 et. seq. (PRWORA). For questions concerning PRWORA status, please contact the U.S. Citizenship and Immigration
Services in the Department of Homeland Security at 1-800-375-5283 or online at http://www.uscis.gov.
AFFIDAVIT OF APPLICANT
I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect.
I understand that failure to provide requested information, making any materially false statement and/or giving any materially false
information in connection with my application for a credential or for renewal or reinstatement of a credential may result in credential
application processing delays; denial, revocation, suspension or limitation of my credential; or any combination thereof; or such other
penalties as may be provided by law. I further understand that if I am issued a credential, or renewal or reinstatement thereof, failure
to comply with the statutes and/or administrative code provisions of the licensing authority will be cause for disciplinary action.
Applicant Signature: ___________________________________________________ Date
#564 (Rev. 3/15)
Ch. 448, Stats.
Page 4 of 4
Committed to Equal Opportunity in Employment and Licensing
