Temporary Physician Initial Licensure Checklist, Study notes of Immunology

Download Temporary Physician Initial Licensure Checklist and more Study notes Immunology in PDF only on Docsity! 1 (125) Temporary Physician Initial Licensure Checklist Contents General Information ............................................................................................................................................................... 2 Instructions: ....................................................................................................................................................................... 2 Qualifications: .................................................................................................................................................................... 3 Application Requirements ................................................................................................................................................... 4-6 Application Fees ...................................................................................................................................................................... 6 2 General Information Instructions: Temporary Physician License 1. Before completing your online application, please read each step below. This will aid you in accurately completing your application and eliminate delays in processing. The application requirements listed below follow the same order as the online application questions. 2. Applications must be submitted to the IDFPR at least 60 days prior to the applicant’s scheduled start date in the postgraduate clinical training program. 3. Disclosure of your U.S. Social Security Number (SSN), if you have one, is mandatory, in accordance with 5 ILCS 100/10-65 to obtain a license. The number may be provided to the Illinois Department of Public Aid to identify persons who are more than 30 days delinquent in complying with a child support order, or to the Illinois Department of Revenue to identify persons who have failed to file a tax return, pay tax, penalty or interest shown in a filed return, or to pay any final assessment or tax penalty or interest, as required by any Tax Act administered by the Illinois Department of Revenue, or to other entities for verification of identification. 4. Any document in a foreign language must be accompanied by an original, notarized translation that has been transcribed by a person other than the applicant, who is fluent in both English and the language of the document. The translator must certify to the above requirements as well as to the accuracy of the translation. 5. The application fee for an initial license is $230.00 and is non-refundable. 6. Applicants may monitor the status of their license application through the IDFPR Online Services Portal. In addition, each GME office has a separate account through the online portal where the hospital may access and monitor the status of temporary license applications submitted by their residents. 7. After the license application is complete, the temporary license shall be issued to the hospital sponsoring the postgraduate clinical training program. The applicant shall not commence training until the temporary license has been issued by the IDFPR designating the effective date and expiration date of the license. 5 4. Applicant who is a graduate of a medical college located outside of the United States or Canada must upload Supporting Document ED-NON completed by the applicant’s medical college. The document must verify that the applicant has met the requirements found under Qualifications (3)(B)(1-3) detailed above. The document must be currently dated and signed by the Dean of the medical college and bear the official seal of the medical college. Incomplete forms will not be accepted. ED-NON form is included at the end of the checklist. 5. Applicant must upload Supporting Document CA-MED completed by the Program Director of a postgraduate clinical training program approved by the IDFPR. The document must be currently dated and signed by the Program Director and bear the official seal of the hospital sponsoring the training program. Incomplete forms will not be accepted. CA-MED form is included at the end of the checklist. 6. Applicant who is a graduate of a medical college located outside of the United States or Canada must upload proof of satisfactory completion of an internship or social service if it was required for the conferral of the applicant’s medical degree. 7. Applicant who is a graduate of a medical college located outside of the United States or Canada must upload proof of current and valid certification issued by the ECFMG. 8. Applicant must verify work history related to the practice of medicine in the five (5) years preceding the date of application. This information may be necessary to demonstrate the applicant’s professional capacity. If the applicant has not been engaged in formal study or training in a program of medicine or engaged in the active practice of medicine in the five (5) years preceding the date of application, applicant must upload proof of professional capacity, i.e. documentation verifying completion of 150 CME hours of AMA PRA Category 1 Credit. 6 9. Applicant who has been granted a license to practice medicine in another U.S. state or in a foreign country must submit official license certifications from the jurisdiction of original licensure and the jurisdiction of current licensure. 10. Applicant must answer questions about: • Health care worker licensure pursuant to 20 ILCS 2105-165(a) • Discipline or action taken by hospitals or other health care entities, insurance carriers, or professional societies or associations • Criminal convictions, discharge from military service or government position, disease or condition that interferes with professional work • Child support, student loan, and tax compliance Application Fees Fees collected through the licensing process are NOT REFUNDABLE OR TRANSFERABLE. Complete License Type Submitted: 1. (125) Temporary Physician License …………………………………………………………………… $230.00 ONLINE PORTAL NOTES: All major credit and debit cards as well as ACH and eCheck are accepted. ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION AFFIDAVIT OF PSYCHIATRY CORE CLERKSHIP ROTATIONS IMPORTANT NOTICE: Completion of this form is necessary to accomplish the requirements outlined in 225 ILCS 60/1 et. seq. (Illinois Compiled Statutes). Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed. IL486-2097 12/13 APPLICANT: This form is to be utilized to verify 2-weeks of psychiatry during another clinical rotation when the medical college has certified to completion of 2-weeks formally and distinctly of a psychiatry rotation. Form must be notarized. PLEASE TYPE OR PRINT IN BLACK INK ONLY. 5. PLEASE CHECK THE TYPE OF LICENSE FOR WHICH YOU ARE APPLYING: 1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH Month Day Year Permanent Physician 036 Temporary Physician 125 __ __ / __ __ / __ __ __ __ 4. SOCIAL SECURITY NUMBER CERTIFYING STATEMENT OF AFFIANT Under penalties of perjury, I declare that the information I have recorded herein is true and correct. Signature of Affiant SUBSCRIBED AND SWORN TO me, this _____ day of ___________________ , 20___ . _________________________________________ NOTARY PUBLIC STATE OF ILLINOIS COUNTY OF ______________________ This is to certify that while enrolled in medical college, I completed four (4) weeks of psychiatry core clerkship rotations. I further certify that of the four (4) weeks completed, at least two (2) of the four (4) weeks were obtained solely and distinctly in psychiatry; and the other two (2) week requirement was included and completed in other clinical rotations and did not overlap with the four (4) week requirement in said other required rotations. The additional two (2) weeks were completed in the following other clinical rotation(s): Rotation(s) Location(s) Dates of Rotation(s) AFFIDAVIT OF PSYCHIATRY CORE CLERKSHIP ROTATIONS OR CONTACT ID NUMBER FROM IDFPR ACKNOWLEDGEMENT LETTER IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure under 225 ILCS 60/1 et. seq. (Illinois Compiled Statutes). Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed. SUPPORTING DOCUMENT ED- NON APPLICANT: Complete the applicant section of this form, then forward it to the school for completion of the remainder of the form. You are authorized to photocopy this form as necessary. 1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH I hereby authorize a school offi cial of the institution named above to furnish to the Illinois Department of Financial and Professional Regulation or its designated testing service the information requested below. 3. PLEASE CHECK THE TYPE OF LICENSE FOR WHICH YOU ARE APPLYING: CERTIFICATION OF EDUCATION NON-LCME ACCREDITED MEDICAL COLLEGE Date Signature of Applicant IL486-2045 1/14 APPLICANT: DO NOT COMPLETE ANY PORTION BELOW THE LINE. Month Day Year __ __ / __ __ / __ __ __ __ ED-NON - Non-LCME Accredited Medical College - Page 1 of 2 4. SOCIAL SECURITY NUMBER Permanent Physician 036 Temporary Physician 125 __ __ __ - __ __ - __ __ __ __ OR CONTACT ID NUMBER FROM A. NAME OF MEDICAL SCHOOL ADDRESS CITY, STATE B. DATES OF ATTENDANCE - EACH YEAR MUST BE LISTED SEPARATELY. DO NOT GROUP DATES OF ATTENDANCE. 1st year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 2nd year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 3rd year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 4th year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 5th year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 6th year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ 7th year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year COUNTRY/PROVIDENCE INTERNSHIP YEAR, IF APPLICABLE From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year C. BASIC SCIENCE COURSES D. INDICATE LENGTH OF ACADEMIC YEAR MONTHS. DATE MEDICAL DEGREE WAS CONFERRED __ __ / __ __ / __ __ __ __ Month Day Year __ __ __ __ __ __ __ __ __ Complete the bottom portion of this page and the reverse side, then return to the applicant. If this part is partially or totally completed by the applicant or altered, the form will not be accepted. Complete dates in form of month/day/year are required where indicated. DEAN OF MEDICAL SCHOOL: Month Day Year Month Day Year Preventative Medicine From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year Pharmacology/Therapeutics From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year Pathology From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year Microbiology/Immunology From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year Biochemistry From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Physiology Anatomy From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __ Month Day Year Month Day Year IDFPR ACKNOWLEDGEMENT LETTER RETURN THIS FORM TO APPLICANT IL486-2045 1/14 SEAL OF COLLEGE I hereby certify that the information above is true and accurate to the records of this medical college and in accordance with Section 11 (A)(2) of the Medical Practice Act and Section 1285.20 of the Administrative Rules. I further certify that the applicant received a medical degree from and was enrolled in this college at the time the core rotations were complet- ed; that the core clinical clerkship rotations were conducted in the clinical teaching facilities either owned or operated by this medical college; government owned or operated; OR formally affi liated or contracted; OR held a verbal affi liation agreement with this medical college. In the case of a written agreement, it is certifi ed that all affi liation agree- ments were in full effect at the time of the applicant's rotation and evaluations verifying passage of each core clerkship rotation were submitted by the supervising physician. ED-NON - Non-LCME Accredited Medical College - Page 2 of 2 N A M E (L a s t, F irs t, M I): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S S # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P ro fe s s io n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date Completed Printed Name of Medical College Print Name of Dean of Medical CollegeSignature of Dean of Medical College E. CORE CLERKSHIP ROTATIONS. COMPLETE DATES IN THE FORM OF MONTH/DAY/YEAR ARE REQUIRED. EACH ROTATION MUST BE A MINIMUM OF FOUR (4) WEEKS IN LENGTH AND COMPLETED WHILE ENROLLED IN THE MEDICAL COLLEGE CONFERRING DEGREE. CORE ROTATIONS WILL NOT BE ACCEPTED OR CO-VALIDATED FROM ANOTHER MEDICAL SCHOOL. (MPA Section 11 (A)(2).) Psychiatry Rotation** Started: Completed: Total WEEKS spent in clinical training rotation: Facility Name: City/State/Country: Check ONE: Government owned/operated facility Medical school owned/operated facility Written Affi liation/Contract with facility Verbal Affi liation Obstetrics/Gynecology Rotation Started: Completed: Total WEEKS spent in clinical training rotation: Facility Name: City/State/Country: Check ONE: Government owned/operated facility Medical school owned/operated facility Written Affi liation/Contract with facility Verbal Affi liation Surgery Rotation Started: Completed: Total WEEKS spent in clinical training rotation: Facility Name: City/State/Country: Check ONE: Government owned/operated facility Medical school owned/operated facility Written Affi liation/Contract with facility Verbal Affi liation Internal Medicine Rotation Started: Completed: Total WEEKS spent in clinical training rotation: Facility Name: City/State/Country: Check ONE: Government owned/operated facility Medical school owned/operated facility Written Affi liation/Contract with facility Verbal Affi liation Pediatrics Rotation Started: Completed: Total WEEKS spent in clinical training rotation: Facility Name: City/State/Country: Check ONE: Government owned/operated facility Medical school owned/operated facility Written Affi liation/Contract with facility Verbal Affi liation ** The 4 week psychiatry core clerkship rotation may be completed as follows: 2 weeks must be completed formally and distinctly in psychiatry as verifi ed by the medical school on this form. The other 2 weeks may be completed in other clinical rotations as verifi ed by the applicant's affi davit. Con- tact the Division for the Affi davit of Psychiatry Core Clerk- ship Rotations form.