Fillable Wisconsin Department of Safety and Professional Services (Wisconsin)

Fill Online, Printable, Fillable, Blank Wisconsin Department of Safety and Professional Services (Wisconsin) Form

Use Fill to complete blank online WISCONSIN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Wisconsin Department of Safety and Professional Services (Wisconsin)

On average this form takes 28 minutes to complete

The Wisconsin Department of Safety and Professional Services (Wisconsin) form is 5 pages long and contains:

  • 0 signatures
  • 55 check-boxes
  • 88 other fields

Country of origin: US
File type: PDF

BROWSE WISCONSIN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
Fax #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
PHYSICIAN ASSISTANT AFFILIATED CREDENTIALING BOARD
PHYSICIAN ASSISTANT CREDENTIALING INFORMATION
An application is not considered complete until all of the following are received at the Department:
Initial Credential
1. Application for Licensure as a Physician Assistant, Form #580
2. Application Fee(s) (See listing on lower left of Page 1.)
3. Physician Assistant Certificate of Professional Education, Form #1504
.
4. National Examination Evidence of passage of the National Commission on Certification of Physician Assistants (NCCPA)
Certification Examination (or equivalent examination approved by the Board). (An applicant who fails to receive a passing
score may reapply twice at not less than 4-month intervals. Should an applicant have 3 unsuccessful attempts the applicant
may not be admitted to an examination unless the applicant submits proof of having completed further professional training
or education as the Board may prescribe.)
5. Any of the following, if applicable:
• Verification of licensure, active or inactive, in any other U.S. state, territory, or jurisdiction, if applicable
• Convictions and Pending Charges, Form #2252
, if applicable
• Malpractice Suits or Claims Form, Form #2829, if applicable
• Name verification (i.e., certified copy of marriage license/divorce degree) if name on all credentials is not the same.
Reciprocal Credential (Applicant is licensed as a physician assistant or physician associate in another U.S. state or territory with
education requirements substantially equivalent to Wis. Admin. Code § PA 2.02.) (Credential must remain current until reciprocity
review is complete.)
1. Application for Licensure as a Physician Assistant, Form #580
2. Application Fee(s) (See listing on lower left of Page 1.)
3. National Examination Evidence of passage of the National Commission on Certification of Physician Assistants (NCCPA
)
Certification Examination (or equivalent examination approved by the Board).
4. Verification of licensure, active or inactive, in any other U.S. state, territory, or jurisdiction
5. Any of the following, if applicable:
• Convictions and Pending Charges, Form #2252
, if applicable
• Malpractice Suits or Claims Form, Form #2829, if applicable
• Name verification (i.e., certified copy of marriage license/divorce degree) if name on all credentials is not the same.
Late Renewal (Wisconsin credential expired more than 5 years)
1. Application for Licensure as a Physician Assistant, Form #580
2. Application Fee(s) (See listing on lower left of Page 1.)
3. Any of the following, if applicable:
• Verification of licensure, active or inactive, in any other U.S. state, territory, or jurisdiction, if applicable
• Convictions and Pending Charges, Form #2252
, if applicable
• Malpractice Suits or Claims Form, Form #2829, if applicable
• Name verification (i.e., certified copy of marriage license/divorce degree) if name on all credentials is not the same.
ALL APPLICANTS Oral Interviews and Personal Appearances
Applicants incurring any of the circumstances listed in Wis. Admin. Code § PA 2.03(1) may be required to complete an oral
examination. If you are asked to appear for an oral examination, an additional examination fee of $266.00 will be required prior to
being scheduled.
#580 (Rev. 4/2022)
Wis. Stat. ch. 448 i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
Fax #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
PHYSICIAN ASSISTANT AFFILIATED CREDENTIALING BOARD
APPLICATION FOR LICENSURE AS A PHYSICIAN ASSISTANT
The Department must deny your application if you are liable for delinquent state taxes, UI contributions, or child support (Wis. Stat. §§ 440.12 and 440.13).
PLEASE TYPE OR PRINT
IN INK
Your name, phone number, e-mail address, and address are available to the public. Check box to withhold street address/PO
Box number, phone number, and e-mail address from lists of 10 or more credential holders (Wis. Stat. § 440.14).
Last Name
First Name
MI
Address (street) (city) (state) (zip code)
- -
Mailing Address (if different) (street) (city) (state) (zip code)
/ /
Social Security Number
Your Social Security 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.
Ethnicity/gender status information is optional.
GENDER ETHNICITY White, not of Hispanic origin American Indian or Alaskan Hispanic
M F Black, not of Hispanic origin Asian or Pacific Islander Other
E-mail Address
School Name
School Address (street, city, state)
Date Diploma Granted
Degree
/ /
APPLICATION FEES: Check applicable box. Make check payable to
DSPS and attach to application. To pay by credit card see Form #3071
.
For Receipting Use Only (23)
I am seeking a Veteran Fee Waiver (for Initial Credential Fee
only, see Page 2 for further information)
Initial Credential
$ 60.00 Initial Credential Fee
$ 60.00 Total Fee Attached
Reciprocal Credential
$ 60.00 Reciprocal Credential Fee
$ 60.00 Total Fee Attached
Late Renewal (WI license expired over 5 years)
$ 60.00 Initial Credential Fee
25.00 Late Renewal Fee
$ 85.00 Total Fee Attached
#580 (Rev. 4/2022)
Wis. Stat. ch. 448 Page 1 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
• Application (Form #580) and appropriate fee
• Letters from all State Boards where licensed, active and
inactive
• Certificate of Professional Education (Form #1504) (not
required for late renewal or reciprocal applicants)
• National Examination scores (NCCPA
or equivalent approved
by the Board) (not applicable to late renewal applicants)
• Malpractice Suits or Claims (Form #2829) and copies of malpractice
suit, court documents with allegations and settlement, if applicable
• Convictions and Pending Charges (Form #2252), if applicable
• Is name on all credentials the same? If not, submit certified copy of
marriage certificate, divorce decree, etc.
ARE YOU A VETERAN? If yes, please view the DSPS website at https://dsps.wi.gov/Pages/Professions/MilitaryLicensureBenefits.aspx for
information and eligibility requirements for veterans, service members, former service members, and their spouses.
If you qualify, are you requesting a waiver of your initial credentialing fee? Yes No
If Yes, provide copy of WI Dept of Veterans Affairs (WDVA) voucher code and list your WDVA Voucher Code #: ____________________
If you qualify, are you requesting equivalency of your military training and experience? Yes No
If Yes, complete and return the Veteran Request Application Addendum (Form #2996). This form must be included with this application.
(You may contact the WDVA at 1-800-947-8387 or dva.wi.gov for assistance in obtaining your WDVA Voucher Code and/or documents related to
your training.)
If you qualify, are you a service member, former service member, or spouse requesting a reciprocal credential? Yes No
If Yes, do not complete this form. You must complete and return the Reciprocal Credential Application for Service Members, Former Service
Members, and Their Spouses (
Form #3982).
CONTINUING EDUCATION AND RENEWAL REQUIREMENTS: Please view the Department website at http://dsps.wi.gov and select
“PROFESSIONS,” then “Physician Assistant.”
PRACTICE: List all professional (employers, practice settings, internships, residencies, fellowships) and nonprofessional activities for the past 7
years preceding the date of application. (If a recent graduate, list from educational program graduation.) All time must be accounted for. (Attach
additional sheets in the same format, if necessary.)
Employer Name
Job Title and Job Duties
(i.e., office staff, food service, PA, etc.)
Location Of Employer
(City/State)
Dates Employed
(Month/Year)
(City)
(From)
/
(State)
(To)
/
(City)
(From)
/
(State)
(To)
/
(City)
(From)
/
(State)
(To)
/
(City)
(From)
/
(State)
(To)
/
#580 (Rev. 4/2022)
Wis. Stat. ch. 448 Page 2 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
I AM OR HAVE BEEN LICENSED IN THE FOLLOWING STATE(S): (Include all active and inactive states.)
For each credential listed above, you are required to have each State Board or territory of the United States submit a letter of verification to the
Wisconsin Physician Assistant Affiliated Credentialing Board. The verification letter(s) must state your date of birth, credential number, date of
issuance, and a statement regarding disciplinary actions.
FOR TEMPORARY LICENSE: (not applicable to Late Renewal or Reciprocal applicants)
Check one:
I plan to take the next National Certifying Examination on: / /
I have taken and passed the National Certifying Examination.
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
3. Have you ever failed to pass any state board examination, national board examination, or NCPPA examination? If yes,
provide details on attached sheet
Yes No
4. 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, felony, or other violation of federal or state law or do you have any
felony, misdemeanor, or other violation of federal or state law charges pending against you in this state or any other?
This includes convictions resulting from a plea of no contest, a guilty plea, or verdict. If yes, submit Convictions and
Pending Charges Form #2252
and required documentation.
Yes No
7. 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
8. 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. Are you registered or licensed in any other profession(s)? If yes, state what profession(s) and in what state(s):
Yes No
10. Have you ever been credentialed under any other name(s)? If yes, state name(s) credentialed under:
Yes No
For the purposes of these questions, the following phrases or words have the following meanings:
"Ability to practice as a Physician Assistant " is to be construed to include all of the following:
1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned physician assistant judgments and to learn and keep abreast of
physician assistant developments; and
2. The ability to communicate those judgments and physician assistant 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, intellectual disability,
emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction and alcoholism. (Continued on Page 4.)
#580 (Rev. 4/2022)
Wis. Stat. ch. 448 Page 3 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
For the purposes of these questions, the following phrases or words have the following meanings: (Continued from Page 3.)
"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.
ANSWER THE FOLLOWING QUESTIONS (Attach additional sheets, if necessary.)
11.
Do you have a medical condition, which in any way impairs or limits your ability to practice as a Physician Assistant
with reasonable skill and safety? If yes, please explain on an attached sheet.
Yes No
12.
Does your use of chemical substance(s) in any way impair, or limit your ability to practice as a Physician Assistant with
reasonable skill and safety? If yes, please explain on an attached sheet.
Yes No
13.
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 on an
attached sheet.
Yes No
14.
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 on an attached sheet.
Yes No
15.
Have you ever been diagnosed as having, or have you ever been treated for pedophilia, exhibitionism, or voyeurism? If
yes, please explain on an attached sheet.
Yes No
16.
Are you currently engaged in the illegal use of controlled dangerous substances?
Yes No
17.
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 on an attached sheet.
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.
Should my legal status change during the application process or after a credential is granted, I understand that I must report this change to the
Wisconsin Department of Safety and Professional Services immediately.
CONTINUING DUTY OF DISCLOSURE
I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this application becomes
invalid, incorrect, or outdated, I understand that I am obliged to provide any necessary information to ensure the information on my application
remains current, valid, and truthful. I understand that credentialing authorities may view acts of omission as dishonesty and that my duty of disclosure
during the application process exists until licensure is granted or denied.
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 of disciplinary action.
By signing below, I am signifying that I have read the above statements (Certification of Legal Status, Continuing Duty of Disclosure, and Affidavit
of Applicant) and understand the obligation I have as an applicant or credential-holder should information I have provided to the Department of
Safety and Professional Services change.
Applicant Signature: Date: / /
(Print and Sign Form)
#580 (Rev. 4/2022)
Wis. Stat. ch. 448 Page 4 of 4
Committed to Equal Opportunity in Employment and Licensing
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Wisconsin Department of Safety and Professional Services (Wisconsin)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document