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MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS, INC. (Medical College of Wisconsin)

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G:/License/DDS/Ack_OMS. 2018 8701 Watertown Plank Road
Post Office Box 26509
Milwaukee WI 53226-0509
(414) 955-4575
FAX (414) 955-6409
MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS, INC.
OMS LICENSURE POLICY ACKNOWLEDGEMENT
I have received and reviewed a copy of the attached MCWAH policy on licensure and agree
to take the required dental regional board examination within the timeline specified in the
policy. I understand failure to pass the required examination within the timeline specified will
result in non-renewal of my Training Agreement.
_________________________________
Name (please print)
_________________________________ _______________________
Signature Date
1. I have successfully passed Parts I and II of the National Board Dental Exam.
Yes
No Explain: _________________________________________
_________________________________________________
_________________________________________________
2. I have successfully passed a dental regional board examination.
Yes Date: _______ Exam Name: _________________________.
No I plan to take __________________________ on ___________.
(Exam Name) (Month/Year)
Please complete, print, sign, date and return this form to the MCWAH office in the envelope
provided. Incomplete or non-receipt of this form in the MCWAH office can cause delays in
the start of your training.
Print Form
G:/License/DDS/Ack_OMS. 2018 8701 Watertown Plank Road
Post Office Box 26509
Milwaukee WI 53226-0509
(414) 955-4575
FAX (414) 955-6409
Medical College
of
Wisconsin Affiliated Hospitals,
Inc.
Institutional
Policy
LICENSURE REQUIREMENT
FOR THE ORAL
AND MAXILLOFACIAL
SURGERY
RESIDENTS
The
MCWAH
Oral and Maxillofacial Surgery (OMS) residents are required to
acquire
the
appropriate
license related credentials as outlined
below.
1. Incoming OMS residents must have successfully passed Parts I and II of the National
Board Dental Examination.
2. OMS residents must pass one of the dental regional or state
examinations
and
be licensed in any state within 18 months after their start
date.
3. Failure to comply with the above policy will result in
non-renewal
of the
training
agreement.
Exceptions to this policy can be made only by the
Executive
Director
of
MCWAH
to accommodate
extenuating circumstances.
Effective Date:
10/5/2002
Revision History:
05/15/2006
Supersedes Policy:
N/A
Review Date:
N/A
Approved By:
Mahendr S. Kochar, MD
Executive Director & DIO
MCWAH
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Completed 23 August 2020

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