Pursuant to
2017 Wisconsin Act 278, beginning August 1, 2018, prior to submitting an application for a credential, an individual may apply to the Department for a determination of whether the individual would be disqualified from obtaining the credential due to his or her conviction record. To apply for a predetermination, please fill out
Form #3085 and submit all required documentation specified on the form. Pursuant to
Wis. Stat. §
111.335(4)(e), the offenses or kinds of offenses that may result in a refusal, bar, or termination of licensure are published under Additional Resources on the left side of this page.
License Information
Fee Reduction
Pursuant to 2017 Wisconsin Act 319, beginning August 1, 2018, an applicant for an initial credential may apply for a reduction of the initial credential fee that is equal to 10% of the initial fee. Qualification is based on the federal adjusted gross income being at or below 180% of the federal poverty guideline prescribed for the applicant's family household size by the United States Department of Health and Human Services. To determine eligibility please visit the United States Department of Health and Human Services website at https://aspe.hhs.gov/poverty-guidelines, prior to submitting Form 3217.
Per
Wis. Stat. § 440.08 (2), the required renewal date for the Licensed Midwives credential is 06/30/even years. Should you receive your initial credential in the months leading up to this date, you are still required to renew your license by the statutorily defined date.
An applicant who fails to comply with a request for information related to the application, or fails to meet all requirements for a permit within 120 calendar days from the date of filing shall submit a new application and fee if a permit is sought at a later date.
- All Licensed Midwives must be registered with the State Vital Records Office, Division of Public Health in the Department of Health and Family Services in order to file birth certificate information:
Wisconsin Vital Records
P.O. Box 309
Madison, WI 53701
Pre-Credential Education Information
Obtain certification from one of the following:
Obtain certification for use of automated external defibrillators (AED's), through a program approved by the Wisconsin
Department of Health Services (DHS).
Temporary Permit
A temporary permit allows the applicant to practice midwifery under the direct supervision of a licensed midwife pending successful completing the requirements for a license.
- An applicant may receive a temporary permit by completion of all application requirements and payment of a $10.00 fee.
- The permit is valid for three (3) years, or until the permit holder ceases to be currently registered or actively engaged as a candidate for nation certification, whichever comes first.
- Temporary permits may be renewed once at the Department's discretion for a period of no more than three (3) years. A permit holder seeking renewal must submit documentation to the Department that satisfies the requirements for an initial permit.
Application for Licensure
| Form | Description |
|---|
|
2792
| Application for Licensed Midwife |
| 3217 | Application for Fee Reduction (This form must accompany the application for the credential) |
|
2790 | Request for Temporary Permit for Licensed Midwife |
|
3194 | Request for Verification of Preceptorship-Apprentice Relationship |
|
2793 | Request for Verification of Certification |
|
2829
| Malpractice Suits or Claims Form (If applicable) |
| 2795 | Informed Consent Form |
|
3085 | Application for Predetermination |
|
2252
| Convictions and Pending Charges |
|
3071 | Fax Payment Form |