Application Status Query

Instructions: 

Please allow one hour after receipt of your status update email for the updates to be reflected in the online checklist.

Please verify the checklist information below, including your address. If your address has changed, please e-mail your application number, name, profession, along with your old and new address. The Credentialing department posts status information following receipt and review of application materials.

As of  :  10/10/2019
Application#  :  686666
Name  :  LAGA, STEPHEN F
Profession  :  Medicine and Surgery, MD
Address  :  Memphis, WI
Application Status  :  Withdrawn (Applicant Request)


Requirements Not Met:
Description Status Comments (Please note, not all requirements will include comments)
USMLE (Step 1, Step 2, Step 3) Not Met
7/25/19: Must come directly from FSMB. Please request an electronic transcript of your USMLE scores taken at: https://usmle.fsmb.org/TranscriptRequests to be forwarded directly to DSPS.
Malpractice Suits or Claims Form #2829 and copies of claims/suits and final settlement, dispositions or dismissal information Not Met
Certificate of Post-Graduate Training (Form #2165) Not Met
Baylor 07/1988 - 06/1991
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Rec'd
Rush 07/1981 - 06/1985
St Louis 07/1979 - 06/1980
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Hospital, Facility, and Employer Verification (Form #2167) Not Met
Il Masonic 01/1991 - 12/2014
Elmhurst 01/1991 - 12/2014
West Sub 01/1991 - 12/2014
St. Anthony 01/1991 - 12/2014
Rush Oak 01/1991 - 12/2014
Thorek 01/1991 - 12/2014
La Grange 01/1991 - 12/2014
Private Prac 07/1991 - 12/2014
Blessing 05/2014 - 08/2014
Christus 08/2016 - 11/2016

Venice 05/2018 - 06/2018
Sparks 8/2018 - 5/2019

Mercy 01/2019 - 03/2019
Application received with lengthy list of facilities. Applicant should have employers who are Joint Commission Certified submit Form 3046 along with a list of affiliated facilities. Those facilities that are NOT associated with a Joint Commissioned employer must each submit Form 2167.
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Hospital, Facility, and Employer Verification (Form #2167) Not Met
7/31/19: Owensboro 08/10/18-08/17/18; Rec’d however facility only verified time of 08/10/18-08/17/18 while you indicate being there from 8/2018 - 5/2019 on your application. Please have facility resubmit form verifying full dates you were at the facility;

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Verification of state license(s) directly from State Board office(s) Not Met
Need:
AZ, CA, FL, , KY, LA, , TN, ,
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Rec'd
IN, IL, TX, WA ND KS AR,

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Oral Exam to be determined after application is completed Not Met

Requirements Met:
Description Status Comments (Please note, not all requirements will include comments)
Application Fee Met
$75
Application Complete Met
Compact License 517-320 issued 8/26/19.
All activities and practice accounted for Met
Certification of Legal Status Completed Met
Electronic affidavit via OLAS Met
Authorization and Waiver, signed (Form #571) Met
Physicians Profile Data Report from AOA or AMA Met
07/31/19: Report: 06/04/19

--IG

7/25/19: If you haven’t already done so, please go to: https://profiles.ama-assn.org/amaprofiles/ Click on the option that reads: Physicians Only-Requests for Profiles to be sent to Licensing Boards;

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Physician Data Center Practitioner Profile Report (Form #1445) Met
Report Date: 6/19/2019
-dd

Report Date: 05/29/2019
-dd
Medical Education Verification Form (Form #2164) Met
Saint Louis University 5/12/1979
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Received Hospital, Facility and Employer Verification Forms Met
10/16/19:REC'D:Turkey 01/2017 - 05/2017
Terrebone 07/2016 - 07/2016
Woodlin 08/2018 - 12/2018
7/25/19: Owensboro 8/2018 - 5/2019
Hinsdale 01/1991 - 12/2014
Lake 09/2014 - 06/2016
Chi St. Lukes 08/2018 - 12/2018-Rec’d form but the wrong the to/end date of privileges/employment. If presently at the facility, they need to indicate that. Please have person completing the form for the facility/employer email missing info directly to our dept to DSPSCREDMEDBD@wi.gov OR the facility must redo and resubmit form #2167 fully completed with full date info;
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St. Josephs 05/2017 - 04/2018
National Practitioner Data Bank Report/Self-query response Met
Reported: 5/30/19


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Social Security Number Met