Temporary Physician Initial Licensure Checklist, Study notes of Immunology

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(125) Temporary Physician

Initial Licensure Checklist

Contents

General Information ............................................................................................................................................................... 2

Instructions: ....................................................................................................................................................................... 2

Qualifications: .................................................................................................................................................................... 3

Application Requirements ................................................................................................................................................... 4-

Application Fees...................................................................................................................................................................... 6

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.

Qualifications:

Temporary Physician License

1. Applicant must have been accepted for specialty training in a program of postgraduate clinical training approved by the IDFPR. The initial temporary license shall be issued for 1, 2, or 3 years based on the program’s accredited length of training as determined by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).
2. Applicant must have completed at least two (2) academic years of instruction in a college, university, or other institution. An academic year is a minimum period of nine (9) months.
3. Applicant must have graduated from a medical college or an osteopathic medical college:

(A) Located in the United States or Canada accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA); or

(B) Located outside of the United States or Canada that meets the following requirements:

(1) The medical college is officially recognized by the jurisdiction in which it is located for the purpose of receiving a license to practice medicine in all of its branches.

(2) The medical program consists of at least two (2) academic years of study in the basic medical sciences; and at least two (2) academic years of study in the clinical sciences. An academic year is a minimum period of nine (9) months.

(3) The clinical sciences must have been completed while enrolled in the medical college which conferred the degree. This must include at least four (4) weeks of core clerkship rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. The core clerkship rotations must have been taken and completed in clinical teaching facilities owned, operated or formally affiliated with the medical college which conferred the degree or under contract in

teaching facilities owned, operated or affiliated with another medical college which is officially recognized by the jurisdiction in which the medical school which conferred the degree is located.

4. Applicant who is a graduate of a medical college located outside of the United States or Canada must be hold

a current and valid certification issued by the Educational Commission for Foreign Medical Graduates (ECFMG).

5. Applicant must have been engaged in the active practice of medicine or engaged in formal study or training in a program of medicine in the five (5) years preceding the date of application. Otherwise, applicant must demonstrate proof of professional capacity, i.e. 150 CME hours AMA PRA Category 1 Credit.
6. Applicant who has been granted a license to practice medicine in another jurisdiction must demonstrate official proof of original licensure and current licensure held.
7. Applicant must be of good moral character, i.e. no conduct/activities that would constitute grounds for discipline under the Medical Practice Act.

Application Requirements

Licensure Method Requirements Submitted:

Temporary Physician Initial Licensure Nonexamination

1. Completed online application including all required information: - Public and Mailing Address - Place of Birth - Date of Birth - Name Change - Education Location - Education Information - Postgraduate Clinical Training Information - Record of Licensure

ONLINE PORTAL

2. Applicant must upload official transcript verifying completion of at least two (2) academic years of instruction in a college, university, or other institution. Transcript must bear official seal and signature of the institution. Note: Graduates from a 6-year medical program, please proceed to next question to upload official transcript verifying 6-year medical program.
3. Applicant must upload official medical college transcript including degree conferred and graduation date. If transcript does not include degree conferred and graduation date, applicant must upload copy of medical diploma.

*For current year U.S. graduates, applicant must upload both an official transcript AND a certification of graduation (Supporting Document ED-MED) issued by the medical college. Both the medical transcript and ED-MED must be issued not more than 30 days prior to applicant’s expected graduation date. Incomplete forms will not be accepted. ED-MED form is included at the end of the checklist.

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.

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/

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

ADMINISTRATOR:

D. BUSINESS ADDRESS STREET, CITY, STATE, ZIP CODE

5. REFER TO REFERENCE SHEET. Record profession name and three digit profession code for which you are making Illinois application.

4. ADDRESS STREET, CITY, STATE, ZIP CODE

6. MAIDEN OR GIVEN SURNAME

1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER

Complete the remainder of this form and return it to the applicant.

A. HOSPITAL/INSTITUTION NAME B. BEGINNING DATE

F. BUSINESS TELEPHONE NUMBER

Area Code ( )

G. YEAR OF POSTGRADUATE TRAINING

Signature of Program Director

Title

Date

S E A L

Print Name of Program Director

I do hereby declare that the above named applicant will be accepted for specialty/residency training as indicated above if,

subsequent to the evaluation of medical education and/or clinical skills by the Department of Financial and Professional

Regulation, the applicant is found to be eligible for licensure.

Profession Name Profession Code

IL486-0272 08/04 (MD)

SUPPORTING DOCUMENT

CERTIFICATE OF ACCEPTANCE FOR SPECIALTY/RESIDENCY PROGRAM

An applicant shall not commence specialty/residency training before he or the hospital/institution

receives written notice of the approval of his application from the Department of Financial and Pro-

fessional Regulation.

Complete the applicant section of this form, then forward it to the hospital/institution that has ac-

cepted you for specialty/residency training, for completion of the remainder of the form.

APPLICANT:

NOTE:

CA-MED

C. ENDING DATE

E. SPECIALTY / RESIDENCY NAME

__ __ __ - __ __ - __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

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.

APPLICANT: Complete the applicant section of this form, then forward it to the school for completion of the re-

mainder of the form.

ED - MED

CERTIFICATION OF GRADUATION

(Current Year Graduates of LCME and

COCA-Accredited Programs Only)

I hereby authorize a school official 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.

IMPORTANT NOTICE: Completion of this form is necessary to accomplish the require- ments 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.

SUPPORTING DOCUMENT

1. NAME LAST FIRST MIDDLE

4. ADDRESS STREET, CITY, STATE, ZIP CODE

6. MAIDEN OR GIVEN SURNAME

2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER

5. REFER TO REFERENCE SHEET. Record profession name and three digit profession code for which you are making Illinois application.

Profession Name Profession Code

Date Signature

A. MEDICAL SCHOOL INFORMATION

Name:

Address:

City, State, Zip:

Phone:

Fax:

B. DATES OF ATTENDANCE

Start:

End:

Degree: MD DO

Applicant will complete all requirements for the medical degree as of and will

graduate on.

IL486-1426 02/12 (L&T)

__ __ __ - __ __ - __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

ED-MED CERTIFICATION OF EDUCATION

Month Day Year

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

Signature of School Official

Print Name of School Official

Title

Date

When this form is certified prior to the actual graduation of the applicant, the school official is responsible for noti-

fying the Department of Financial and Professional Regulation of any failure on the part of the applicant to complete

the requirements for graduation.

I certify that the information recorded herein is true and correct according to the official records of this institution.

SCHOOL

S E A L

SCHOOL OFFICIAL: Complete the bottom portion of this page and return ALONG with a current official medical school

transcript. DO NOT certify this form more than 30 days prior to the graduation date.

C.

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 official 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/

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/

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 affiliated or contracted; OR held a verbal

affi liation agreement with this medical college. In the case of a written agreement, it is certified that all affiliation 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

NAME (Last, First, MI): ____________________________________________SS#: ___________________ Profession:

___________________

Date Completed Printed Name of Medical College

Signature of Dean of Medical College Print Name 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 Affiliation/Contract with facility

Verbal Affiliation

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 Affiliation/Contract with facility

Verbal Affiliation

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 Affiliation/Contract with facility

Verbal Affiliation

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 Affiliation/Contract with facility

Verbal Affiliation

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 Affiliation/Contract with facility

Verbal Affiliation

** The 4 week psychiatry core clerkship rotation may be

completed as follows: 2 weeks must be completed formally

and distinctly in psychiatry as verified by the medical school

on this form. The other 2 weeks may be completed in other

clinical rotations as verified by the applicant's affidavit. Con-

tact the Division for the Affidavit of Psychiatry Core Clerk-

ship Rotations form.