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Wisconsin Department of Safety and Professional Services (Wisconsin)

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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
MEDICAL EXAMINING BOARD
INFORMATION FOR COMPLETING MEDICINE AND SURGERY APPLICATION FORM
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 Department’s 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.
FEDERATION CREDENTIALS VERIFICATION SERVICE (FCVS):
The Department accepts the physician information profile completed by FCVS through the Federation of State Medical Boards. If you
choose to utilize FCVS, you will not need to submit DSPS forms to verify the following: Medical School Education (Form #2164),
Post-Graduate Training (Form #2165), reporting of licensure exam scores, Physician Data Center Profile from the Federation of State Medical
Boards (Form #1445), National Practitioner Data Bank Report, or ECFMG certificate. You may obtain this service online at
www.fsmb.org.
AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
• DSPS Application (Form #570) and fee
• Copy of ECFMG certificate if a Foreign Graduate
(FCVS), (not applicable for Late Renewal*)
• Malpractice Suits or Claims (Form #2829
) and copies
of malpractice suit, court documents with allegations
and settlement, if applicable
• Joint Commission Certified Hospital, Facility, and
Employer Verification (Form #3046
), if applicable
• Letters from all State Boards where licensed, including
active and inactive licenses
• Medical Education Verification (Form #2164
)
(FCVS), (not applicable for Late Renewal*)
• Signed Authorization and Waiver (Form #571)
• Certificate of Post-Graduate Training (Form #2165)
(FCVS), (not applicable for Late Renewal*)
• Physician Profile Data Report from the American
Medical Association (AMA), or American Osteopathic
Association (AOA)
• National Board, FLEX, State Board, USMLE or
LMCC score (FCVS), (not applicable for Late
Renewal*)
• Physician Data Center Profile from the Federation of State
Medical Boards (Form #1445
) (FCVS)
• National Practitioner Data Bank Report (FCVS)
•
Hospital, Facility, and Employer Verification (Form
#2167)
• Proof of 30 hours of CE completed in the previous
biennium (applicable for Late Renewal*)
• Convictions and Pending Charges (Form #2252
), if
applicable
* Late Renewal More Than 5 Years After License Expiration
MAILING INSTRUCTIONS: Mail the Application for Licensure, the appropriate fee, and documentation to the following address:
MAILING ADDRESS: EXPRESS DELIVERY:
DSPS DSPS
ATTN: MEDICAL EXAMINING BOARD ATTN: MEDICAL EXAMINING BOARD
P.O. BOX 8935 4822 MADISON YARDS WAY
MADISON, WI 53708-8935 MADISON, WI 53705
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
ENDORSEMENT OF FLEX AND/OR USMLE EXAM SCORES:
Please request an electronic transcript of your USMLE and/or FLEX exam score(s) taken at: https://usmle.fsmb.org/TranscriptRequests to be
forwarded directly to the Department.
ENDORSEMENT OF NATIONAL BOARDS:
Please request that a copy of your exam score(s) be forwarded directly to Wisconsin Medical Examining Board. Forms are available at
www.nbme.org
. NBME will forward this information directly to the Department.
ENDORSEMENT OF NATIONAL BOARD OF OSTEOPATHIC MEDICAL EXAMINERS CERTIFICATION:
Submit your request for an “Endorsement of Certification/Official Transcript” and fee to the National Board of Osteopathic Medical
Examiners (NBOME) at www.nbome.org
. Transcripts must be sent directly from NBOME to the Department.
ENDORSEMENT OF LMCC: (Must be taken after January 1, 1978)
Direct certification from the Medical Council of Canada (LMCC) is required and must be sent directly from LMCC to the
Department.
RECIPROCITY OF ANOTHER STATE BOARD EXAM TAKEN PRIOR TO 1972:
Scores must be certified by the State Board where taken and sent directly to the Department. The State Board submitting the
information must include all the subjects covered in the examination, scores received, general average, date of the examination,
license number, date of issuance, status of licensure, and any information pertaining to disciplinary action.
VERIFICATION OF OTHER MEDICAL LICENSES:
You are required to have each State Board in which you have ever been licensed submit letters of verification to the Department. The
letters must indicate your date of birth, license number, date of issuance, and a statement regarding disciplinary actions. These letters
will be required in order to complete your application for licensure. Verifications can be submitted directly to the Department via
email to DSPSCredMedBd@wisconsin.gov
.
NATIONAL PRACTITIONER DATA BANK:
All candidates must request the “Practitioner Request for Information Disclosure” (Self-Query) from the National Practitioners Data Bank. Self-
Queries (NPDB) can be found at http://www.npdb.hrsa.gov
.
Select the option that reads “Self-Query.” After the NPDB has completed your request, they will send the Self-Query response directly to you.
Once received, you will need to forward a copy of the response to the Department. This report may be emailed to
DSPSCredMedBd@wisconsin.gov
or faxed to (608) 251-3036. If you have further questions regarding this report, contact the NPDB helpline
at (800) 767-6732.
PHYSICIAN PROFILE DATA REPORT FROM AMA OR AOA:
All MD’s applying for licensure must complete the Physician Profile Data Report. This request can be made from the following
website: https://profiles.ama-assn.org/amaprofiles
.
All DO’s applying for licensure must use the AOA website at https://www.aoaprofiles.org/.
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 ii
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
ORAL EXAMS:
The oral exam process in the State of Wisconsin was created under Wis. Admin. Code § MED 1.06(1). If you are selected to appear
for an oral exam, you will be scheduled to appear before the Review Panel at one of the regularly scheduled Board meetings. If you
are selected for an oral examination, the additional oral examination fee of $266.00 will be required prior to being scheduled for this
exam.
FOREIGN GRADUATES:
• ECFMG Certificate: Graduates of foreign medical schools must provide a copy of an ECFMG certificate with “valid
indefinitely” status.
• Fifth Pathway Certificate: If you participated, you must submit a copy of your Fifth Pathway certificate from the program
you attended.
VISITING PHYSICIAN:
This license is designed for a graduate of a medical school, or an osteopathic college approved by the Board, who is invited to
serve on the academic staff of a medical school in this state as a Visiting Physician.
A Visiting Physician Application process is almost identical in processing time and of the documentation required as a permanent
license, with the following additional requirement. A signed letter from the President or Dean of a medical school, facility, or college in
Wisconsin indicating that the applicant intends to teach, research, or practice medicine and surgery at a medical education facility,
medical research facility, or medical college in this State as a Visiting Physician.
After your completed application is received by the Department, it will be reviewed by two (2) Members of the Board. Upon approval,
you will be issued a Visiting Physician License, valid for one (1) year and remaining valid only while the license holder is actively
engaged in teaching, researching, or practicing medicine and surgery, and is lawfully entitled to work in the United States. This may be
renewed at the discretion of the Board.
The holder of a Visiting Physician license may practice medicine and surgery providing such practice is entirely limited to the medical
education facility, medical research facility, or the medical college where the license holder is teaching, researching, or practicing
medicine and surgery, and only within the terms and restrictions established by the Board.
ADMINISTRATIVE PHYSICIAN:
This license is designed for an applicant whose primary responsibilities are those of an administrative or academic nature.
The holder of an Administrative Physician license may not examine, care for, or treat patients. An Administrative Physician license does
not include the authority to prescribe drugs or controlled substances, delegate medical acts, issue opinions regarding medical necessity, or
conduct clinical trials on humans.
Applicants for an Administrative Physician license must also meet the same qualifications for licensure as applicants applying under Wis.
Stat. § 448.05 (2)(a) or (b).
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 iii
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 for Licensure to Practice Medicine and Surgery.”
Academic Medicine 37 Otolaryngology 67
Administrative Medicine 71 Otorhinolaryngology - ENT 15
Aerospace Medicine 33 Pain 66
Alcoholism - Chemical Dependency 49 Pathology 16
Allergy - Immunology 01 Pathology - Clinical 17
Anesthesiology 02 Pathology - Surgical Anatomic 72
Aviation Medicine 32 Pediatrics 18
Dermatology 03 Pediatrics - Other 60
Emergency Medicine 31 Perinatology 62
Endocrinology 56 Pharmacology - Clinical 48
Family Medicine 925 Physical Medicine and Rehabilitation 19
Gastroenterology 06 Preventive Medicine 09
General Practice 08 Proctology 36
Genetics 61 Psychiatry 20
Geriatrics 29 Psychiatry - Child 21
Hand Surgery 64 Public Health 22
Hebiatrics 46 Radiation - Oncology 70
Hematology 07 Radiology 53
Hyperbaric Medicine 65 Radiology - Diagnostic 43
Immunology - Infectious Diseases 47 Radiology - Nuclear Medicine 68
Institutional Medicine 39 Radiology - Ultrasound 69
Internal Medicine 04 Radiology – Interventional 946
Internal Medicine - Cardiology 05 Research 34
Internal Medicine - Pulmonary Medicine 45 Retired 24
Neonatology 63 Rheumatology 57
Nephrology 40 School Physician 52
Neurology 10 Surgery - Cardiovascular 44
Neuromuscular Medicine 926 Surgery - Colon and Rectal 54
Neurophysiology 51 Surgery - General 25
Nuclear Medicine 23 Surgery - Maxillofacial 58
Obstetrics and Gynecology 12 Surgery - Neurological 11
Occupational Medicine 30 Surgery - Peripheral Vascular 59
Oncology 38 Surgery - Plastic 26
Ophthalmology 13 Surgery - Thoracic 27
Orthopedic Surgery 14 Urology 28
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 iv
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
MEDICAL EXAMINING BOARD
APPLICATION FOR LICENSE TO PRACTICE MEDICINE AND SURGERY
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, address, telephone number, and e-mail address are available to the public. Check box to withhold street
address/PO Box, telephone number, and e-mail address from lists of 10 or more credential holders (Wis. Stat. § 440.14).
Last Name
First Name
Former / Maiden Name(s)
Address (street, city, state, zip code)
Daytime Telephone Number
- -
Mailing Address (if different)
Date of Birth
/ /
Social Security Number
- -
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.
Ethnicity/gender status information is optional.
ETHNICITY: White, not of Hispanic origin American Indian or Alaskan Hispanic
Black, not of Hispanic origin Asian or Pacific Islander Other
SEX: M F
Have you ever been licensed in Wisconsin as a Physician? Yes No If yes, list your credential number:
E-mail Address
Specialty (see page iv for a listing of codes)
Specialty Code (see page iv for a listing of codes)
Medical School
Medical School Address (street, city, state)
Degree Please check one: Date Degree Granted
MD DO
/ /
APPLICATION FEES: Please check applicable box. Make check payable to DSPS and attach to
this application. To pay by credit card see Form 3071.
Please check this box if you are applying for Administrative Physician Licensure
For Receipting Use Only (20/21/220/221/876)
I am seeking a Veteran Fee Waiver
(for Initial Credential Fee only, see page 2 for
further information)
Endorsement of Steps 1, 2 and 3 of USMLE
$60.00 Initial Credential Fee
$60.00 Total Fee Attached
Endorsement of National Boards (MD or
DO), (NBME or NBOME)
$60.00 Initial Credential Fee
$60.00 Total Fee Attached
Endorsement of FLEX
$60.00 Initial Credential Fee
$60.00 Total Fee Attached
Endorsement of LMCC (taken after 1/1/78)
$60.00 Initial Credential Fee
$60.00 Total Fee Attached
Reciprocity of State Board Exam (Taken
Prior to 1972)
$60.00 Reciprocal Credential Fee
$60.00 Total Fee Attached
Visiting Physician
$59.00 Reciprocal Credential Fee
$59.00 Total Fee Attached
Late Renewal More than 5 Years After
License Expiration
$ 60.00 Renewal Fee
$ 25.00 Late Renewal Fee
$ 85.00 Total Fee Attached
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 Page 1 of 5
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 #570) and appropriate fee
• Physician Profile Data Report from the American Medical
Association or American Osteopathic Association
• Copy of ECFMG Certificate if a Foreign Graduate (FCVS), (not
applicable for Late Renewal*)
• Joint Commission Certified Hospital, Facility, and Employer
Verification (Form #3046), if applicable
• Medical Education Verification Form (Form #2164) (FCVS),
(not applicable or Late Renewal*)
• Signed Authorization and Waiver Form (Form #571)
• Letters from all State Boards where licensed, active and inactive
• National Board, FLEX, State Board, USMLE or LMCC score
(FCVS), (not applicable for Late Renewal*)
• Certificate of Post-graduate Training (Form #2165)
(FCVS), (not applicable for
Late Renewal*)
• Proof of 30 hours of CE
completed in the previous biennium
(applicable for Late Renewal*)
* Late Renewal More Than 5 Years After License Expiration
• Convictions and Pending Charges (Form #2252), if applicable
• Malpractice Suits or Claims (Form #2829) and copies of malpractice
suit, court documents with allegations and settlement, if applicable
• Physician Data Center Practitioner Profile Report from the Federation of
State Medical Boards (Form #1445), (FCVS)
• Hospital, Facility and Employer Verification (Form #2167)
• Copy of a license to practice medicine and surgery in another state or
Canada and a letter of good standing, only required for Visiting
Physician
• National Practitioner Data Bank Report (FCVS)
• Signed Letter from the President or Dean of a medical school, f
acility,
or college in Wisconsin indicating that the applicant intends to teach,
research, or practice medicine and surgery at a medical education
facility, medical research facility, or medical college in this State as a
Visiting Physician, only required for Visiting Physician
• 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 https://dsps.wi.gov/ and select
“Professions,” then “Physician.”
POST-GRADUATE TRAINING/FELLOWSHIPS, PRACTICE, AND OTHER ACTIVITIES: List in chronological order from the date of
graduation of medical school to the present time. The below information must include professional and nonprofessional activities. (Attach
additional sheets, if necessary, using the same format.)
For all hospitals, facilities, and employers where you are or have been employed, had or held staff privileges or appointments for five years preceding
the date of application, the Hospital, Facility and Employer Verification form (Form #2167) must be submitted.
Please Note: The dates provided on this application must match the dates provided on the verification provided by the facility. Discrepancies
will cause delays in the application process.
DATES
(Month, Year)
TYPE
NAME OF SCHOOL, HOSPITAL
CLINIC OR OTHER
LOCATION
(City, State and Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 Page 2 of 5
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
POST-GRADUATE TRAINING/FELLOWSHIPS, PRACTICE, AND OTHER ACTIVITIES, continued. . .
DATES
(Month, Year)
TYPE
NAME OF SCHOOL, HOSPITAL
CLINIC OR OTHER
LOCATION
(City, State and Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To)
/
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
(From) /
(To) /
Intern
Resident
Fellow
Practice
Other
(City)
(State)
(Country)
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 Medical Examining Board. The verification letter(s) must state your date of birth, credential number, date of issuance, and a statement
regarding disciplinary actions.
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 Page 3 of 5
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 registered or licensed in any other profession(s)?
If yes, state what profession(s) and in what state(s):
Yes No
2. Have you ever been credentialed under any other name(s)? If yes, state name(s) credentialed under:
Yes No
3. Are you familiar with the state health laws and rules and regulations of the Wisconsin Department of Health regarding
communicable diseases? https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/145
https://docs.legis.wisconsin.gov/statutes/statutes/252
Yes No
4. Have you ever failed to pass any state board examination, national board examination (NBME or NBOME), FLEX, or
USMLE examination? If yes, provide details below:
Yes No
5. 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
6. 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
7. Have you ever been reprimanded, demoted, disciplined, cautioned, placed on probation, limited in your practice or
privileges, placed on or taken leave greater than 90 days, or terminated by any employer, educational institution,
training program, licensing board, hospital, medical facility, professional society, specialty board, or medical body for
any reason? If yes, attach a sheet providing details about the action, including the name of the entity and date of
action.
Yes No
8. Have any suits or claims ever been filed against you as a result of professional services? If yes, Malpractice Suits or
Claims (Form #2829).
Yes No
9.
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.
Yes No
10.
Have you ever been convicted of a misdemeanor, felony, or other violation of federal, state, or local law or do you
have any felony, misdemeanor, or other violation of federal, state, or local law charges pending against you in this state
or any other? This includes municipal ordinances resulting only in monetary fines or forfeitures and convictions
resulting from a plea of no contest, a guilty plea, or verdict.
Yes No
11. 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
12. If yes to Question 10 above, did you apply for a predetermination of the conviction(s)?
If yes, proceed to Question 13.
If no, submit Convictions and Pending Charges Form #2252 and supporting documentation.
Yes No
13.
If yes to Question 12, did you receive a
letter
indicating the conviction(s) did not disqualify you from licensure?
If yes, proceed to Question 14.
If no, submit Convictions and Pending Charges Form #2252 and supporting documentation.
Yes No
14.
If yes to Question 13, since the date of the letter indicating you were not disqualified from licensure, have you been
convicted of a misdemeanor, felony, or other violation of federal, state, or local law or do you have any felony,
misdemeanor, or other violation of federal, state, or local law charges pending against you in this state or any other?
This includes municipal ordinances resulting only in monetary fines or forfeitures and convictions resulting from a
plea of no contest, a guilty plea, or verdict.
If yes, submit Convictions and Pending Charges Form #2252 and supporting documentation for each conviction
and pending charge since the date of the letter.
If no, submit Convictions and Pending Charges Form #2252 without previously submitted documentation.
Yes No
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.
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 Page 4 of 5
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 previous page)
"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.
"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 direction of
a licensed health care practitioner.
ANSWER THE FOLLOWING QUESTIONS. (Attach additional sheets if necessary.)
15. Do you have a medical, physical, or mental condition which in any way impairs or limits your ability to practice
medicine with reasonable skill and safety? If no, you may skip Question 16. If yes, please explain.
Yes No
16. If yes to Question 15, are the limitations or impairments caused by your medical, physical, or mental condition reduced
or ameliorated because you receive ongoing treatment (with or without medications), participate in a monitoring
program or 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. Do you use chemical substance(s), as defined above, that in any way impair, or limit your ability to practice medicine
with reasonable skill and safety? If yes, please explain.
Yes No
18. Are you currently (within the last two years) engaged in the illegal use of controlled dangerous substances? Yes No
19. If yes to Question 18, are you 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
20. Have you ever been diagnosed as having, or have you ever been treated for pedophilia, exhibitionism, or voyeurism?
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.
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.
Signature:
Date:
/ /
(Print and Sign Form)
#570 (Rev. 7/2021)
Wis. Stat. ch. 448 Page 5 of 5
Committed to Equal Opportunity in Employment and Licensing
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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Completed 31 August 2021

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