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Form 173 Score Report Form PDF

The document provides instructions for requesting official USMLE transcripts for students or graduates enrolled at an institution. It outlines the following: 1) The fee for requesting 1-10 transcripts is $65. Payment should be submitted using the included Payment for Service(s) Requested form, checking the box for "USMLE Transcript." 2) The institution official should complete sections 1-2 of the Institutional Request for an Official USMLE Transcript form and distribute copies of page 2 to each student. 3) Students must complete the consent form on page 2 authorizing the release of their transcript to the institution. 4) Completed forms and payment should be submitted to ECFMG and will be processed in

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1K views3 pages

Form 173 Score Report Form PDF

The document provides instructions for requesting official USMLE transcripts for students or graduates enrolled at an institution. It outlines the following: 1) The fee for requesting 1-10 transcripts is $65. Payment should be submitted using the included Payment for Service(s) Requested form, checking the box for "USMLE Transcript." 2) The institution official should complete sections 1-2 of the Institutional Request for an Official USMLE Transcript form and distribute copies of page 2 to each student. 3) Students must complete the consent form on page 2 authorizing the release of their transcript to the institution. 4) Completed forms and payment should be submitted to ECFMG and will be processed in

Uploaded by

barneylovesbagels
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© © All Rights Reserved
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Institutional Request for an Official USMLE Transcript

Form 173

A USMLE transcript includes a complete results history of all USMLE Steps or Step Components taken and for which
results are available, as of the date the transcript is processed. For more information, see Scores & Transcripts on the
USMLE website.
ECFMG does not provide USMLE transcripts to state medical boards or other licensing authorities. For information on
ECFMG certification status, contact the Certification Verification Service at ECFMG at (215) 386-5900 or visit
www.ecfmg.org/cvs.
To request a transcript for Step 3, contact the Federation of State Medical Boards (FSMB) at (817) 868-4000 or visit the
FSMB website at www.fsmb.org.
To obtain a USMLE transcript for a student/graduate enrolled at your institution, please complete and sign Sections 1
and 2 of the form below.
Sections 3 and 4 appear on page 2 of this document. Print or type the institution information requested in the space
provided and photocopy page 2 of this document. Distribute one copy of each new document to each student/graduate
for whom you are requesting an official transcript.
To submit payment, complete all information requested on the Payment for Service(s) Requested (Form 900), which is
included with this request form.
You should check USMLE Transcript in item 2 of the payment form.
Return the completed Form 173 and consent authorization documents (Form 173-B) for each student/graduate for
whom you are requesting a transcript along with payment (Form 900) by fax, to (215) 386-3185, or mail to ECFMG,
3624 Market Street, 4th Floor, Philadelphia, PA 19104-2685 USA. Include a payment of US$65.00 for one through
10 transcripts, US$130.00 for 11-20 transcripts, US$195.00 for 21-30, US$260.00 for 31-40, etc.
Please allow approximately four weeks for your request to be processed.
Direct all inquiries to ECFMG at (215) 386-5900.

1
Contact Name

Title

Institution Name

Signature of School Official

//
Signature (Using the Latin Alphabet)

The fee for requesting one through 10 official USMLE transcripts is $65.00.
To submit payment, complete all information requested on the Payment for
Service(s) Requested (Form 900). Form 900 is included with this request
form. You should check USMLE Transcript in item 2 of the payment form.

Date (Month/Day/Year)

For Office Use Only

Submit the completed payment form with your Institutional Request for an
Official USMLE Transcript.

This form is available on the ECFMG website at www.ecfmg.org.

Form 173, Rev. SEP 2014


Page 1 of 2

MEDICAL SCHOOL STUDENT/GRADUATE CONSENT FOR RELEASE OF USMLE


TRANSCRIPT

3
Recipient
Information
(To be
completed by
School
Official)

Contact Name

Title

Institution Name

Mailing Address: Line 1

Mailing Address: Line 2

City

State/Province

ZIP/Postal Code

Country

Country/Area Code and Telephone Number

Country/Area Code and Fax Number

E-mail Address

4
Authorization
(To be
completed by
the Student or
Graduate for
whom the
USMLE
Transcript is
being
requested)

I hereby authorize and request the Educational Commission for Foreign Medical Graduates to release my official United States Medical Licensing
Examination (USMLE) transcript to the individual at the institution listed above.

//

Signature of Student
(Using the Latin Alphabet)

Date (Month/Day/Year)

Name of Student
(Please Print)

USMLE/ECFMG ID #

Date of Birth
(Month/Day/Year)

---
/ /
This form is available on the ECFMG website at www.ecfmg.org.

Form 173-B, Rev. SEP 2014


Page 2 of 2

Payment for Service(s) Requested


Form 900

P
A
Y
M
E
N
T

BY MAIL/COURIER: ECFMG, 3624 Market Street, 4th Floor, Philadelphia, PA 19104-2685 USA
TELEPHONE: (215) 386-5900 FAX: (215) 386-3185 INTERNET: www.ecfmg.org

1
Enter your
Identification
Number.
Enter your
name.

USMLE / ECFMG
Identification Number:

Middle Name(s)

First Name(s)

Generational
Suffix (Jr, Sr,
II, III, IV)

Last Name(s) (Surname or Family Name)

2
Indicate the
service(s)
for which
you are
providing
payment.

Application for ECFMG Certification ($65)


Application for USMLE Step 1/Step 2 CK ($865 per exam*)
Application for USMLE Step 2 CS ($1,505 per exam)
Extension of USMLE Step 1/Step 2 CK Eligibility Period

($70 per exam)

Testing Region Change: USMLE Step 1/Step 2 CK


($65 per region change*)

Score Recheck: USMLE Step 1/Step 2 CK/Step 2 CS


($80 per exam)

ERAS Token ($105) ERAS Applicants: Do NOT use this



form to pay for transmission of your USMLE transcript via


ERAS. Instead, login to AAMCs MyERAS website.

USMLE Transcript ($65 per request form up to 10

transcripts) ERAS Applicants: Do NOT use this


form to pay for transmission of your USMLE transcript via
ERAS. Instead, login to AAMCs MyERAS website.

(A)

Charge my credit card.

Select a
method of
payment
and
complete all
information
requested.

Credit Card
Number:

Do NOT
send cash.

Address of Card Holder:

ECFMG Exam Chart ($50 per request form up to three copies)


ECFMG CSA History Chart ($50 per request form up to 10 copies)
CVS State Board ($35)
EVSP (J-1 VISA) ($285)
Duplicate ECFMG Certificate ($50)
Name Change on ECFMG Certificate ($50)
File Copy Fee ($25)
Translation Fee Medical School Transcript ($200)
*International test delivery surcharges also may apply and must be
included in payment. For the list of fees, see the ECFMG website at
www.ecfmg.org/fees.
Previous Balance/Other (Specify):

Exp. Date
(Month/Year):
Check One:

VISA

MASTERCARD

DISCOVER

AMERICAN EXPRESS

Name of Card Holder:

City:
State:
Country:
Zip/Postal Code:
By signing below, I authorize ECFMG to charge my credit card in the amount indicated above.
Signature of Card
Holder:
(B)

My check, bank draft, or money order made payable to ECFMG is enclosed.


Payment must be made in U.S. funds through a U.S. bank. Include your USMLE/ECFMG Identification Number on your check.

For detailed information on ECFMGs Payment and Refund policies, refer to the ECFMG Information Booklet and to the ECFMG website at www.ecfmg.org.
This form is available on the ECFMG website at www.ecfmg.org.
Form 900, Rev. MAR 2015
Page 1 of 1

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