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Physician - Application Forms

Application for Endorsement by Exam 
Form # Title/Description
570  Application to Practice Medicine and Surgery 
Do not complete this application if you previously held a license with the state of Wisconsin. You must apply as re-registration (see re-registration section below).
571  Authorization and Waiver 
2165  Certification of Post Graduate Training Not necessary if utilizing FCVS.
2252  Convictions and Pending Charges If applicable
1445  Disciplinary Inquiries Report Not necessary if utilizing FCVS.
3046 Joint Commission Certified Hospital, Facility and Employer Verification
2167  Hospital, Facility and Employer Verification Form 
2829  Malpractice Suits or Claims Form 
2164  Medical Education Verification Form Not necessary if utilizing FCVS.
 
Application for Minnesota Licensees
Form # Title/Description
2862  Application For License to Practice Medicine and Surgery for Individuals with a Current Unrestricted Minnesota License You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
571  Authorization and Waiver 
2252  Convictions and Pending Charges If applicable.
1445  Disciplinary Inquiry Report from the Federation of State Medical Boards 
2861  Information for completing Application for Individuals to Practice Medicine and Surgery with a Current Unrestricted Minnesota License 
2829  Malpractice Suits or Claims Form If applicable.
   
Application For Re-Registration
Form # Title/Description
1542  Application for Re-Registration of License to Practice Medicine and Surgery 
You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
571  Authorization and Waiver 
2252  Convictions and Pending Charges If applicable
1445  Disciplinary Inquiries Report 
3046 Joint Commission Certified Hospital, Facility and Employer Verification
2167  Hospital, Facility and Employment Verification Form 
546  Information for Completing Medicine and Surgery Application  
2829  Malpractice Suits or Claims Form 
 
Application for Temporary Camp Physician or Locum Tenens
Form # Title/Description
568  Application for Temporary Camp Physician or Locum Tenens License  
You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
2252  Convictions and Pending Charges If applicable
1445  Disciplinary Inquiries Report  Not necessary if utilizing FCVS.
2829  Malpractice Suits or Claims Form 
 
Application for Temporary Education Permit
Form # Title/Description
2601  Affidavit of Hospital Authority 
3050 Temporary Education Permit Certificate of Professional  Education Form This form must be returned directly from your school.
2329  Application for Renewal of Temporary Educational Permit 
564  Application For Temporary Educational Permit 
2252  Convictions and Pending Charges If applicable
 
Application For Visiting Professor
Form # Title/Description
570  Application to Practice Medicine and Surgery 
You must also complete AMA or AOA Physician Profile Data Report. Go to the License Information page for direct link.
571  Authorization and Waiver 
2165  Certification of Post Graduate Training Not necessary if utilizing FCVS.
2252  Convictions and Pending Charges If applicable 
1445  Disciplinary Inquiries Report Not necessary if utilizing FCVS.
2829  Malpractice Suits or Claims Form 
2164  Medical Education Verification Form Not necessary if utilizing FCVS
 

Other Information/Forms

Physician- License Information