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Physician - Application Forms


The State of Wisconsin Medical Examining Board is pleased to offer the new online application process for medical and osteopathic physicians called the Uniform Application for Physician State Licensure (UA).  The UA will benefit physicians by reducing redundancy in filling out multiple applications when applying for licensure in multiple states.  Physicians will be able to apply to multiple states by filling out the UA once, then directing it to additional states.  Physicians applying via OLAS  can import their UA information into their Wisconsin license application, leaving only the state-specific instructions and addendums of the application to be completed.  Visit the Federation of State Medical Boards website for further information.

Application for Endorsement by Exam, Re-Registration, Administrative Physician and Visiting Physician 
Form # Title/Description
570  Application to Practice Medicine and Surgery
571  Authorization and Waiver 
2165  Certification of Post Graduate Training Not necessary if utilizing FCVS.
2164 Medical Education Verification Form Not necessary if utilizing FCVS.   
1445Physician Data Center Practitioner Profile Report from the Federation of State Medical Boards  Not necessary if utilizing FCVS.  
2167Hospital, Facility and Employer Form Not required for applicants who have only been employed in a strictly training capacity and have not done any moonlighting outside of their training.  
3046 Joint Commission Certified Hospital, Facility and Employer Verification This form is ONLY to be used for employment agencies to verify a complete list of facilities placed at under the agency's employment.  If only a single facility/employer is being verified, Form #2167 above should be used.
2829  Malpractice Suits or Claims Form (Only needed if applicable)
2252Convictions and Pending Charges  
3074License Transition Addendum
 
Application for Minnesota Licensees
Form # Title/Description
2862  Application For License to Practice Medicine and Surgery for Individuals with a Current Unrestricted Minnesota License 
571  Authorization and Waiver 
1445  Physician Data Center Practitioner Profile Report from the Federation of State Medical Boards
2829  Malpractice Suits or Claims Form (Only needed if applicable)
2252Convictions and Pending Charges 
 
Application for Temporary Camp Physician or Locum Tenens
Form # Title/Description
568  Application for Temporary Camp Physician or Locum Tenens License 
1445  Physician Data Center Practitioner Profile Report from the Federation of State Medical Boards 
2829  Malpractice Suits or Claims Form (Only needed if applicable)
2252Convictions and Pending Charges 
 
Application for Resident Educational License (formerly the Temporary Education Permit)
Form # Title/Description
564Application for a Resident Educational License 
2601  Affidavit of Hospital Authority This form must be submitted directly by training facility.
3050 Certificate of Professional  Education Form This form must be returned directly from your school.
2252 Convictions and Pending Charges 
2329  Application for Renewal of Resident Educational License 
 

Other Information/Forms

Physician- License Information