DEPARTMENT OF HEALTH

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Department of Health
Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, FL 32399-3257

GENERAL INFORMATION/INSTRUCTIONS

Application for Chiropractic Examination & Initial Licensure

HOW TO APPLY FOR FLORIDA CHIROPRACTIC LICENSURE

*** PLEASE TYPE OR PRINT IN BLACK INK - PLEASE READ CAREFULLY ***

1. FLORIDA LAWS & RULES:
You may download a copy of Section 460, Florida Statutes and Rule Chapter 64B2, Florida Administrative Code at
www.doh.state.fl.us/mqa/chiro/index.html It is important to read this in order to determine your eligibility prior to
applying, and to familiarize yourself with the statutes and board rules regarding your application for licensure and the
practice of the chiropractic profession within the State of Florida.

2. APPLICANT'S QUESTIONS REGARDING APPLICATION STATUS:
Within thirty (30) days after we receive your application and fee, we will send you an acknowledgment letter informing
you of any deficiencies in your application and the specific items required to complete your application. If you do not
receive notice that we have received your application within forty-five (45) days of the date you mailed it, or if you have
questions concerning the requirements for licensure, please do not hesitate to contact this office. If you have
questions concerning whether or not we have received items which we require you to arrange to be sent to this office
by a third party (such as official transcripts, licensure verifications from state licensing agencies); please check with the
third party first to see if the required documentation has been sent. As a reminder to all applicants, please understand
that Chapter 456.013(1)(a), Florida Statutes, provides that an incomplete application shall expire one year after initial
filing with the department.

3. EXAMINATION INFORMATION:
The Chiropractic Licensure Examination consists of laws and rules CBT. This exam is offered year round.

a. ACUPUNCTURE CERTIFICATION APPLICANTS: A complete application is required for the Chiropractic
Acupuncture Certification. To be eligible for the certification, an official grade notice documenting that you
have successfully completed the National Board of Chiropractic Examiners (NBCE) Acupuncture Examination
must be submitted directly from the National Board of Chiropractic Examiners to this board office. Proof of
completion of an approved 100 hour course in acupuncture, from issuing agency. Current verification of each
license you have held or currently hold is required from each licensing authority. Fingerprinting is not required
when applying for acupuncture certification only.

b. RETAKE APPLICANTS (within one year): Applicants who are retaking the examination are required to
submit a new, complete application for each examination sitting. Retake applicants are required to resubmit the
fingerprint card and fee every year. Transcripts received by the board office DO NOT have to be resubmitted;
however, licensure verifications must be resubmitted.

c. SPECIAL TESTING ACCOMMODATIONS: Special Testing Accommodations Due to Disability: Rules
regarding examination procedures for candidates with disabilities are outlined in Rule 64B-1.005, F.A.C. In
accordance with Chapter 64B-1.005, F.A.C., the Department will provide reasonable and appropriate special
testing accommodations to candidates with physical or learning disabilities to the extent permitted by cost, exam
administration constraints, examination security considerations and availability of resources. Candidates
requesting special testing accommodations must file a completed application (Part I and Part II) with Testing
Services, by the final published application deadline for the licensure examination for which the accommodation is
requested. It is the responsibility of the candidate to provide adequate documentation of his/her disability.
Requests from Candidates Previously Receiving Special Testing Accommodations: Applicants who have
previously received special testing accommodations for an examination and need accommodation for another
examination or for a retake of the same examination in Florida must file a reapplication with Testing Services,
Bureau of Operations each time accommodation is needed. Special Testing Accommodations Due to
Religious Conflicts: Modification to reporting times or alternate test dates may be requested by candidates who,
due to their religious beliefs, cannot attend the examination at the scheduled reporting time(s) or on the scheduled
DH-MQA 1147, Revised 04/2010 Page 1 of 26
Rule 64B2-11.001, F.A.C.
date(s). Candidates requesting such accommodation must make application with Testing Services, by the final
published application deadline for the licensure examination for which the accommodation is requested. Each
request should be accompanied by a letter from a religious leader specifying the religious restrictions that apply.

4. YES/NO QUESTIONS:
All questions with a "Yes or No” answer must be marked with either a "Yes" or "No" as no other response is
acceptable. For questions which require a brief explanation or description to “Yes” answers, your responses must be
sufficiently detailed to ascertain the relevant dates, institution/organization names, and a brief synopsis of the
reasons (i.e., the final charges or substantiated allegations only) the institution/organization took the disciplinary or
other action (i.e., probation, limitation, suspension, revocation, voluntary relinquishment in lieu of disciplinary action, or
any other adverse action). HOWEVER, IF A QUESTION CONTAINED IN THIS APPLICATION IS NOT APPLICABLE
ANSWER “N/A” IN THE NO COLUMN. Certified or notarized documentation of final disposition to “yes”
answers is required.

5. ADDITIONAL SPACE NOTE:
Should any of the sections in the Application fail to provide sufficient space for the requested information, use an
additional page or the reverse side of the Application page on which the question is located. Always number the
additional information with the corresponding number in the Application.

6. FINGERPRINT CARD/BACKGROUND CHECK:
Effective October 1, 2007, the Division of Medical Quality Assurance will begin scanning fingerprint cards and
electronically submitting fingerprints to FDLE/FBI for background screening. The FDLE/FBI fee is $48.00. Two
properly executed fingerprint cards must be submitted with each original application. The fingerprint cards will be used
by the Florida Department of Law Enforcement (FDLE) and Federal Bureau of Investigation (FBI) to conduct a
background check as required by law. See the instructions below for the proper procedures for completing/executing
the fingerprint card. Failure to accurately follow these instructions may result in additional costs, and will result in a
significant processing delay. Fingerprint cards can only be provided by mail. To obtain the fingerprint cards you need
to log on to www.fldoh.sofn.net

7. FINGERPRINT CARD/BACKGROUND CHECK PROCESSING FEE:
The fee for processing your fingerprint card and background check is $48.00. This fee is non-refundable and must be
submitted with each original application. The fee may be paid by certified check or money order. Failure to remit this
fee or any other omissions in completing the application will result in processing delays.

8. FEDERAL PRIVACY ACT:
Under the Federal Privacy Act, disclosure of social security numbers is voluntary unless specifically required by federal
statute. In this instance, social security numbers are mandatory pursuant to Title 42 United States Code,
Sections 653 and 654: and sections 456.013, 409.257(7) and 409.259(8), F. S. Social security numbers are used to
allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with
child support obligations. Social security numbers must also be recorded on all professional and occupational license
applications and will be used for license verification pursuant to, unless exempt as outlined in the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub. L. 193, Section 317.

Note: If you do not fill in your social security number, your application will be delayed. You must possess a
social security number prior to receiving a license.

9. If the package that you are mailing to the Board Office contains money, mail to:

DEPARTMENT OF HEALTH
Post Office Box 6330
Tallahassee, Florida 32314-6330

10. If the package that you, or anyone on your behalf, is mailing to the Board Office does NOT contain money,
mail to:

Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, Florida 32399-3257

11. You can also visit the board’s web site for additional information at www.doh.state.fl.us/mqa/chiro/index.html

DH-MQA 1147, Revised 04/2010 Page 2 of 26
Rule 64B2-11.001, F.A.C.
NOTE: Language interpretation services are available to applicants for licensure who have limited-English
proficiency or a hearing/speech impairment. If you need an interpreter in order to talk with your application
processor, please indicate that information when you call the board office. An interpreter and the processor will
call you back shortly in order to handle your call.

DH-MQA 1147, Revised 04/2010 Page 3 of 26
Rule 64B2-11.001, F.A.C.
SUPPORTING DOCUMENTS -- THE FOLLOWING ITEMS MUST BE INCLUDED WITH YOUR APPLICATION

COMPLETE AND RETURN BOTH COPIES OF THE FIRST PAGE OF THE APPLICATION AS ONE IS USED FOR
EXAMINATION SCHEDULING.

1. Fee Schedule: A certified check or money order in the appropriate amount, made payable to the Department of
Health, must be attached to your application. Please staple the check or money order to page 1 of the application on
the upper left part of the form. Your application will not be processed without these fees. These fees are required by
law and include the following:

Laws & Rules CBT:

Application Fee $100.00 (non-refundable)
Examination Fee $170.00
Total Fee $270.00

Acupuncture Certification: (optional)
Application Fee $100.00 (non-refundable)
Total Fee $100.00

Criminal History Background Check:
Total Fee $ 48.00 (non-refundable)

Initial License Fee:
Initial License Fee $355.00 (refundable if fail)
Acupuncture Initial License Fee $105.00

2. Prevention of Medical Errors: A 2 hour course on the prevention of medical errors must be documented with the
original certificate of attendance or a notarized copy. Please contact CE Broker for available courses,
www.cebroker.com

3. Final Official Undergraduate Transcript: A final official transcript must be sent directly from the educational
institution/college to this office. Transcripts submitted by the applicant or indicating “issued to student” are not
acceptable; a copy of your diploma will not be accepted in lieu of an official transcript. Please note that it is your
responsibility to follow-up with your educational institutions to ensure that they have received and complied with your
requests.

4. Final Official Chiropractic College Transcript: A final official transcript stating the degree and date of confirmation
must be sent directly from the chiropractic school/college to this office. Transcripts submitted by the applicant or
indicating “issued to student” are not acceptable. A copy of your diploma is not acceptable. Please note that it is your
responsibility to follow-up with your educational institutions to ensure that they have received and complied with your
requests. A student in a school or college of chiropractic accredited by the Council on Chiropractic Education or its
successor in the final year of the program must have the college submit a letter with your matriculation date and
anticipated date of graduation.

5. Official Licensure Verification: The licensure verification forms included with this application package must be sent
to each state or other licensing authority where you currently hold or have held a license to practice, regardless of the
status of the license. These forms must be sent directly from each state licensing agency to this office. Please note
that it is your responsibility to follow-up with licensing agencies to ensure that they have received and complied with
your requests. A copy of your license will not be accepted in lieu of official verification from the licensing
agency.

6. National Board of Chiropractic Examiners (NBCE) Scores: Official NBCE Scores for parts I, II, III, IV & PT must be
sent directly from National Board to this office. Again, please note that it is your responsibility to follow-up with NBCE
to ensure that they have received and complied with your requests. The board may require an applicant who
graduated from an institution accredited by the Council on Chiropractic Education more than 10 years before the date
of application to the board to take the National Board of Chiropractic Examiners Special Purposes Examination for
Chiropractic, or its equivalent, as determined by the board. The board shall establish by rule a passing score.

7. Acupuncture Course (Acupuncture Certification Applicants Only): Proof of completion of an 100 hour course in
acupuncture from the issuing agency and proof of completion of NBCE Acupuncture Examination.

DH-MQA 1147, Revised 04/2010 Page 4 of 26
Rule 64B2-11.001, F.A.C.
8. Financial Responsibility/Professional Liability Coverage: The Professional Liability form included with this
application package must be completed by selecting the appropriate option and submitting the required documentation.
Proof of liability coverage is not required until your license is issued and must be sent directly from the company to the
board office.

9. Two Fingerprint Cards: Effective October 1, 2007, the Division of Medical Quality Assurance will begin
scanning fingerprint cards and electronically submitting fingerprints to FDLE/FBI for background screening.
The FDLE/FBI fee is $48.00. The fingerprint cards must be properly executed and attached to your application. Two
properly executed fingerprint cards are required to be submitted with the application. See the instructions below under
the heading “Completing the Fingerprint Card” for the proper procedures for completing/executing the fingerprint cards.

10. Request for an Application for Special Testing Accommodations: You must complete this form and mail it to the
address shown on the bottom of the application. This form does not constitute an application for special testing
accommodations. The Department will mail you an application to be completed and returned back to the Bureau of
Operations, Testing Services.

11. National Practitioner Data Bank Self-Query: Applicants are required to complete a self query to the National
Practitioner Data Bank (NPDB) and upon receipt of the report, provide the Board office with a copy. A fee is charged
to furnish this information.

NPDB
Post Office Box 10832
Chantilly, VA 22021
(800) 767-6732
www.npdb-hipdb.com/welcomesq.html

PLEASE NOTE--YOUR APPLICATION IS NOT CONSIDERED COMPLETE UNTIL ALL SUPPORTING DOCUMENTS
AND FEES HAVE BEEN RECEIVED BY THIS OFFICE.

DH-MQA 1147, Revised 04/2010 Page 5 of 26
Rule 64B2-11.001, F.A.C.
Computer Based Test Information

Once you have received your notification of eligibility from the board office, you may contact Prometric to pay
the CBT examination fee and schedule your examination.

COMPUTER BASED TEST FEES
Please Note—Fees are required in addition to the fees already submitted to the board.

Chiropractic Laws/Rules Fee – $50.50

 This fee shall be paid to Prometric.
 The fee may be paid by Visa, MasterCard, American Express, or electronic check.
 Payment will be due at the time of scheduling.

SCHEDULING:

 You must schedule your examination appointment with Prometric. You may contact Prometric via
telephone or Internet at the contact information listed on the last page of the Candidate Information
Booklet (CIB).
 When contacting Prometric, you must select/state that you are taking a
“Florida Department of Health” examination.
 You will be required to provide your social security number
(as your testing/eligibility ID) in order to schedule your examination.
 All examination dates, times, and locations will be scheduled on a first-come first-serve basis.

RESCHEDULING:

 You may reschedule your examination appointment as needed, without penalty, up to two days prior to
your examination.
 If you attempt to reschedule your examination within two days of your appointment, you will be
considered a ―late cancel.‖ You must then wait at least three (3) days from the date of your
appointment before you may reschedule your examination. You will be required to repay the
examination fee.
 One form of valid, current, government-issued identification with both a signature and a photo.
 Driver‟s License; OR
 State I.D. card; OR
 Military I.D.; OR
 Passport

NOTE: The name on your eligibility record (from your examination application submitted to the Board
Office) must match the name on the ID you present at the Prometric testing center. If these names do not
match, you will not be allowed to test. To change the name on your eligibility record, contact the Board Office.

DH-MQA 1147, Revised 04/2010 Page 6 of 26
Rule 64B2-11.001, F.A.C.
CHIROPRACTIC MEDICINE

INITIAL APPLICANT CHECKLIST

MAKE COPIES OF ALL DOCUMENTS for your records, prior to mailing the originals to the department. Use this
worksheet to check off items as you prepare.

______1. FEES: All applicants are required to pay a non-refundable $100 application processing fee. All initial
applicants are required to pay a non-refundable fee for the criminal history background check. Vendor fees are
paid directly to the vendor and not to the DOH.

INCLUDE ALL FEES IN “ONE Certified Check or Money Order” made payable to the DEPARTMENT OF HEALTH.

 _____ Examination (Laws/Rules):
Application Fee $ 100.00 (non-refundable)
Laws/Rules Fee $ 170.00 (CBT)
Background Check Fee $ 48.00 (non-refundable)
Licensure Fee $ 350.00
Unlicensed Activity Fee $ 5.00
Total Fee $ 673.00

 _____ Acupuncture Certification: (optional)
Application Fee $100.00 (non-refundable)
Licensure Fee $100.00
Unlicensed Activity Fee $ 5.00
Total Fee $205.00

______2. SOCIAL SECURITY NUMBER page is required

______3. ALL PAGES OF APPLICATION: (13 pages total)
 Both copies of page 1 are required for exam scheduling purposes
 Statement page (last page) must contain your original signature
 All questions must be answered. Questions may not be answered with “refer to attached resume”. If a
particular question does not apply, please enter N/A in the appropriate field. If explanation or clarification is
needed or if any of the sections do not contain sufficient space for the requested information, use an additional
sheet of paper and make note on the application question that additional information is attached. Always
number the additional information with the corresponding number of the question in the application.
 All “yes” answers must be supported by a certified copy of the final disposition of the case from the clerk of
court in the county where the conviction took place.

______4. CHIROPRACTIC COLLEGE:
Request the chiropractic college to send a final transcript directly to the board office. This final transcript must
contain your exact date of matriculation into the DC program and a graduation date. Transfer credits must
indicate what institution the credits came from. A student in a school or college of chiropractic accredited by
the Council on Chiropractic Education or its successor in the final year of the program must have the college
submit a letter indicating their anticipated date of graduation.

______5. UNDERGRADUATE HOURS/DEGREE:
Request the college/university to send transcripts directly to the board office.

DH-MQA 1147, Revised 04/2010 Page 7 of 26
Rule 64B2-11.001, F.A.C.
______6. LICENSE VERIFICATIONS:
Verification must come directly from the licensing authority; a copy of your license is not sufficient and will not
be accepted in lieu of official verification, regardless of the status of the license.

______7. NATIONAL BOARD SCORES (I, II III, IV & PT), and (ACUPUNCTURE), if applicable.
NBCE must send the scores directly to the board office. Student copies will not be accepted.

______8. NPDB SELF-QUERY:
All applicants are required to complete a self query to the National Practitioners Data Bank. All self query
applications must be submitted electronically through the NPDB-HIPDB web site. In addition, a signed and
notarized copy must be mailed to the Data Banks to complete the self query process. Applicants who do not
have access to the Internet may call NPDB-HIPDB Customer Service Center for assistance at 1-800-767-6732
(TDD 703-802-9395). Once the Data Banks receive your notarized copy they will mail you a report from both
data banks. Each applicant is required to provide the NPDB report to the board office to complete their exam
file. The report from HIPDB is not required and cannot be substituted for the NPDB report. Please make sure
you send the correct report to the board office.

______9. COMPLETION OF ACUPUNCTURE COURSE (if applicable):
Applicants who want to include an acupuncture certification must have the school provide verification of
completion of the required 100 hour course in acupuncture.

_______10. 2 HOUR PREVENTION of MEDICAL ERRORS COURSE:
All new licensees are required to provide proof of completion of a 2 hour prevention of medical errors course
to have the initial license issued. (You may take the exam prior to submitting this course)

_______11. STATEMENT OF FINANCIAL RESPONSIBILITY
All applicants are required to complete this statement on the application. Proof of insurance is not required.

______12. LIABILITY CLAIMS:
All applicants are required to answer the questions on the application. If you answer any of these questions
“yes” you must complete and include EXHIBIT 1 – REPORT ON PROFESSIONAL LIABILITY CLAIMS AND
ACTIONS

_______13. TWO FINGERPRINT CARDS:
All applicants are required to complete/submit two fingerprint cards. Applicants who download the application
will need to use the email link on the web site to request that a fingerprint card be mailed to them. Law
enforcement offices usually will not provide you with a fingerprint card and if they do, it is usually not
acceptable for use in the application process. All areas of the fingerprint card must be completed.

DH-MQA 1147, Revised 04/2010 Page 8 of 26
Rule 64B2-11.001, F.A.C.
CHIROPRACTIC MEDICINE

RE-EXAMINATION APPLICANT CHECKLIST

MAKE COPIES OF ALL DOCUMENTS for your records, prior to mailing the originals to the department. Use this
worksheet to check off items as you prepare. The exam application should be mailed to DOH at least 30 days after
receiving a failing score.

______1. FEES: All applicants are required to pay a non-refundable $100 application processing fee. All retake
applicants are required to pay a non-refundable $48.00 fee for the criminal history background check every 12
months. Vendor fees are paid directly to the vendor and not to the DOH.

INCLUDE ALL FEES IN “ONE Cashier Check or Money Order” made payable to the DEPARTMENT OF
HEALTH.

 _____ Re-examination:

Application Fee $100.00 (non-refundable)
Examination Fee $170.00 (CBT)
Total Fee $270.00

______2. SOCIAL SECURITY NUMBER page is required

______3. ALL PAGES OF APPLICATION:
 Both copies of page 1 are required for exam scheduling purposes
 Statement page (last page) must contain your original signature
 All questions must be answered. Questions may not be answered with “refer to attached resume”. If a
particular question does not apply, please enter N/A in the appropriate field. If explanation or clarification is
needed or if any of the sections do not contain sufficient space for the requested information, use an additional
sheet of paper and make note on the application question that additional information is attached. Always
number the additional information with the corresponding number of the question in the application.
 All “yes” answers must be supported by a certified copy of the final disposition of the case from the clerk of
court in the county where the conviction took place.
DOCUMENTATION SUBMITTED FOR A PRIOR EXAM DOES NOT NEED TO BE
RESUBMITTED.

______4. CHIROPRACTIC COLLEGE:
Retake applicants are not required to resubmit this document.

______5. UNDERGRADUATE HOURS/DEGREE:
Retake applicants are not required to resubmit this document.

______6. LICENSE VERIFICATIONS:
Retake applicants are required to submit updated license verifications every 12 months. Verification must come
directly from the licensing authority; a copy of your license is not sufficient and will not be accepted in lieu of
official verification, regardless of the status of the license.

______7. NATIONAL BOARD SCORES (I, II, III, IV & PT), and (ACUPUNCTURE), if applicable.
Retake applicants are not required to resubmit this document.

DH-MQA 1147, Revised 04/2010 Page 9 of 26
Rule 64B2-11.001, F.A.C.
______8. NPDB SELF-QUERY:
Retake applicants are not required to resubmit this document unless it has been more than 12 months since the
board received a report.

______9. STATEMENT OF FINANCIAL RESPONSIBILITY
All applicants are required to complete this statement on the application. Proof of insurance is not required.

_____10. LIABILITY CLAIMS:
All applicants are required to answer the questions on the application. If you answer any of these questions
“yes” you must complete and include EXHIBIT 1 – REPORT ON PROFESSIONAL LIABILITY CLAIMS AND
ACTIONS

______11. FINGERPRINT CARD:
Retake applicants are not required to resubmit this card unless it has been more than 12 months since the
board ran a background check. Applicants who download the application will need to use the email link on the
web site to request that a fingerprint card be mailed to them. Law enforcement offices usually will not provide
you with a fingerprint card and if they do, it is usually not acceptable for use in the application process. All
areas of the fingerprint card must be completed. To obtain fingerprint cards you to log on to www.fldoh.sofn.net

_____12. 2 HOUR PREVENTION of MEDICAL ERRORS COURSE:
All new licensee’s are required to provide proof of completion of a 2 hour prevention of medical errors course
to have the initial license issued. (You may take the exam prior to submitting this course)

DH-MQA 1147, Revised 04/2010 Page 10 of 26
Rule 64B2-11.001, F.A.C.
LICENSURE VERIFICATION

TO: State Licensing Agency FROM: ____________________________
(Applicant’s Name)

DATE: ____________________________
(Date sent to state board)

NOTE: IMMEDIATE ATTENTION PLEASE

I am applying for Chiropractic licensure in the State of Florida. The Board of Chiropractic requires verification of licensure
by each jurisdiction in which I hold or have ever held licensure. Please complete the verification of licensure section and
mail to the address listed below.
*********************************************************
VERIFICATION OF LICENSURE:

State of: _________________________________________

Name of Licensee: _________________________________________

License Number: _________________________________________

Issue Date: _________________________________________

Expiration Date: _________________________________________

Status of License: _________________________________________

HAS THIS LICENSE EVER BEEN DISCIPLINED BY YOUR BOARD?
( ) YES ( ) NO

If YES, please attach certified copies of official documentation of action taken.

__________________________________________ (State Seal)
Signature of Person Verifying Not valid without Seal

__________________________________________
Print Name of Above Person

__________________________________________
Title of Person Verifying

__________________________________________
Date Signed

Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, FL 32399-3257
DH-MQA 1147, Revised 04/2010 Page 11 of 26
Rule 64B2-11.001, F.A.C.
MEMORANDUM

TO: Florida Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, FL 32399-3257

FROM: ___________________________________________
(Please type or print)

______________________________________________________________________________________________
I hereby certify that I have completed an educational course on the prevention of medical errors as required by Florida
Statutes. I understand that within the next two years I may be required to submit proof of my completion of this course if
my license is selected for audit.

I state that these statements are true and correct. I further understand and acknowledge that providing false information
may result in the denial of my application, disciplinary and/or criminal penalties as provided in Florida Statutes 456.072,
456.067, 775.082, 775.083, or 775.084.

_________________________________________
Signature (Required)

_________________________________________
Date (of signature)

_________________________________________
Date of Examination

Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, FL 32399-3257
DH-MQA 1147, Revised 04/2010 Page 12 of 26
Rule 64B2-11.001, F.A.C.
REQUEST FOR AN APPLICATION FOR
SPECIAL TESTING ACCOMMODATIONS

To apply for special testing accommodations you may:

1) mail this request to our office and an application will be mailed to you;
2) fax this request to our office at (850) 487-9537 and an application will be mailed to you or
3) visit our website at www.doh.state.fl.us to download the application.

This form is not an application for special testing accommodations. Please mail the application to the address
below. The Department or its testing provider will make the arrangements for special testing accommodations only if your
application is approved.

------------------------------------------------------------------------------------------
Please print or type the following information.

Name__________________________________________________________________________________________

Address________________________________________________________________________________________

_________________________________________________________________________________________

Telephone Number (W) ( )_____________________________ (H) ( )______________________________

Profession for which you are requesting testing accommodations for: ___________________________________

Disability Request? _____Yes _____No

Religious Conflict Request? _____Yes _____No

English as Second Language _____ Yes _____No (Not an option for all professions)

Have you received special testing accommodations for the State of Florida before? ____Yes ____No

RETURN THIS FORM TO:

Department of Health
Bureau of Operations, Testing Services
ATTN: Special Testing Coordinator
4052 Bald Cypress Way, Bin #C90
Tallahassee, FL 32399-3260
(850) 245-4252 Phone
(850) 487-9537 FAX
(Do not send this request to the Board Office)

DH-MQA 1147, Revised 04/2010 Page 13 of 26
Rule 64B2-11.001, F.A.C.
CONFIDENTIAL AND EXEMPT FROM PUBLIC RECORDS
DISCLOSURE
Florida Department of Health
Board of Chiropractic Medicine

This page is exempt from public records disclosure. The Department of Health is required and authorized to collect Social
Security Numbers relating to applications for professional licensure pursuant to Title 42 USCA § 666 (a)(13). For all
professions regulated under Chapter 456, Florida Statutes, the collection of Social Security Numbers is required by
section 456.013 (1)(a), Florida Statutes.

Name: ___________________________________________________
Last First Middle

Social Security Number: ____________________________________

APPLICANT HISTORY: (If you answer YES to the following questions, please provide additional sheets, the
relevant dates and circumstances of such treatment and/or addiction along with the names and addresses of the
medical practitioners or hospitals who performed such treatment.)

1. In the last five years, have you been enrolled in, required to enter into, or participated in any drug and/or alcohol
recovery program or impaired practitioner program for treatment of drug or alcohol abuse that occurred within the
past five years? [ ] YES [ ] NO

2. In the last five years, have you been admitted or referred to a hospital, facility or impaired practitioner program for
treatment of a diagnosed mental disorder or impairment? [ ] YES [ ] NO

3. During the last five years, have you been treated for or had a recurrence of a diagnosed mental disorder or that
has impaired your ability to practice chiropractic medicine within the past five years? [ ] YES [ ] NO

4. During the last five years, have you been treated for or had a recurrence of a diagnosed physical disorder that
has impaired your ability to practice chiropractic medicine? [ ] YES [ ] NO

5. In the last five years, were you admitted or directed into a program for the treatment of a diagnosed substance-
related (alcohol/drug) disorder or, if you were previously in such a program, did you suffer a relapse within the
last five years? [ ] YES [ ] NO

6. During the last five years, have you been treated for or had a recurrence of a diagnosed substance-related
(alcohol/drug) disorder that has impaired your ability to practice chiropractic medicine within the last five years?
[ ] YES [ ] NO

Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, FL 32399-3257

DH-MQA 1147, Revised 04/2010 Page 14 of 26
Rule 64B2-11.001, F.A.C.
BOARD OF CHIROPRACTIC MEDICINE
APPLICATION FOR LICENSURE
(Client: 501)
Board Office Copy

READ/DOWNLOAD APPLICATION INSTRUCTIONS FOR IMPORTANT INFORMATION
1. APPLICATION CATEGORY/APPLICABLE FEES:
(TYPE OR PRINT LEGIBLY IN BLACK INK– CHECK APPROPRIATE CATEGORIES)
[ ] INITIAL EXAMINATION (1010) TOTAL: $673.00
o Laws/Rules
[ ] RE-EXAMINATION (1011) TOTAL: $270.00
o Laws/Rules Month/year of prior exam: ______________________________
[ ] INITIAL APPLICATION (1012) TOTAL: $205.00
o Acupuncture Certification (optional)

APPLICANT PROFILE:
2. NAME:______________________________________________________________________
(Last) (First) (Middle)
a. Have you ever changed your name through marriage or through action of a court? [ ] YES [ ] NO
______________________________________________________________________________________
If 'yes', list: Name(s) (Last, First, Middle) and Date(s) of changes

3. ADDRESS:

a. MAILING ADDRESS (where you receive mail):

____________________________________________________________________________________
(Street and number or PO Box) (City) (State/Province) (Zip/Postal Code) (Country)

b. PRIMARY PRACTICE/PHYSICAL ADDRESS (where you can be located-NO PO BOX):

_____________________________________________________________________________________
(Street and number) (City) (State/Province) (Zip/Postal Code) (Country)

c. TELEPHONE: _(______)_________________________ _(______)____________________________
Home: Area Code/Phone Number Work: Area Code/Phone Number

d. EMAIL ADDRESS: ________________________________________________

4. PERSONAL DATA:
HEIGHT: ________________________ WEIGHT: ________________________________
EYE COLOR: ____________________ HAIR COLOR: ____________________________
BIRTH DATE: ___________________ BIRTH PLACE: __________________________________
(Month/Day/Year) (City)(State/Province)(Country)

We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniformed Guidelines on
Employee Selection Procedure (1978) 43 FR38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does
not in any way affect your candidacy for licensure.

RACE: Caucasian [ ] Black [ ] Hispanic [ ] Asian [ ] Native American [ ] Other [ ]
SEX: Male [ ] Female [ ]
 Would you be willing to provide health services in special needs to shelters or to help staff
disaster medical assistance teams during time of emergency or major disaster? [ ] Yes [ ] No

FOR OFFICE USE ONLY-DO NOT WRITE BELOW THIS LINE

EXAM DATE: _____________________________ CANDIDATE NO: ______________________

[ ] ORIGINAL or [ ] RE-TAKE #____________
[ ] LAWS/RULES

DH-MQA 1147, Revised 04/2010 Page 15 of 26
Rule 64B2-11.001, F.A.C.
BOARD OF CHIROPRACTIC MEDICINE
APPLICATION FOR LICENSURE
(Client: 501)
Testing Office Copy

READ/DOWNLOAD APPLICATION INSTRUCTIONS FOR IMPORTANT INFORMATION
1. APPLICATION CATEGORY/APPLICABLE FEES:
(TYPE OR PRINT LEGIBLY IN BLACK INK– CHECK APPROPRIATE CATEGORIES)

[ ] INITIAL EXAMINATION (1010) TOTAL: $673.00
o Laws/Rules
[ ] RE-EXAMINATION (1011) TOTAL: $270.00
o Laws/Rules Month/year of prior exam: ______________________________
[ ] INITIAL APPLICATION (1012) TOTAL: $205.00
o Acupuncture Certification (optional)

3. ADDRESS:

a. MAILING ADDRESS (where you receive mail):

____________________________________________________________________________________
(Street and number or PO Box) (City) (State/Province) (Zip/Postal Code) (Country)

b. PRIMARY PRACTICE/PHYSICAL ADDRESS (where you can be located-NO PO BOX):

_____________________________________________________________________________________
(Street and number) (City) (State/Province) (Zip/Postal Code) (Country)

c. TELEPHONE: _(______)_________________________ _(______)____________________________
Home: Area Code/Phone Number Work: Area Code/Phone Number

d. EMAIL ADDRESS: ________________________________________________

FOR OFFICE USE ONLY-DO NOT WRITE BELOW THIS LINE

EXAM DATE: _____________________________ CANDIDATE NO: ______________________

[ ] ORIGINAL or [ ] RE-TAKE #____________
[ ] LAWS/RULES

DH-MQA 1147, Revised 04/2010 Page 16 of 26
Rule 64B2-11.001, F.A.C.
NAME:_________________________________________________________________

5. If you were not born in the United States, are you a citizen of the U.S.? [ ] YES [ ] NO

If you are a Naturalized citizen please provide date and place of Naturalization:

______________________ & __________________________________________________
(Month/Day/Year) (City/State/Province/Country)

If you are not a U.S. citizen, please provide alien number: ___________________________

6. Have you ever been in the United States Military and/or Public Health Service? [ ] YES [ ] NO

_________________________________________________________________________________________
If „yes‟ list branch of service, rank, dates of service (Enclose copy of discharge form)

a. Have charges, now or ever, been brought against you by any branch of the
Armed Services of the United States? [ ] YES [ ] NO
If „yes‟ explain on a separate sheet, providing accurate details.

7. Do you hold or have you ever held a license to practice Chiropractic or any
other profession in any US State or territory, or foreign country? [ ] YES [ ] NO
If „yes‟ list State or Country/Profession/License Number (use back of page)
Verification of each license must be received directly from the licensing authority, regardless of status of license.

___________________________________________________________
State or Country/Profession/License Number

a. List the year and state/province/country where you legally began practice:

___________________________________________________________
(Year) (State/Province/Country)

8. NAME OF PRIMARY PRACTICE (if different from name on page 1/2):

_________________________________________________________________________________________

9. FAX NUMBER: _______________________________
(Area Code/Fax Number)

10. E-MAIL ADDRESS: ________________________________________

11. OTHER PRACTICE LOCATION(S):

___________________________________________________________________________________________________________
(Practice Name) (Street and Number) (City) (State/Province) (Zip/Postal Code)

____________________________________________________________________________________________________________________________________
(Practice Name) (Street and Number) (City) (State/Province) (Zip/Postal Code)

___________________________________________________________________________________________________________
(Practice Name) (Street and Number) (City) (State/Province) (Zip/Postal Code)

DH-MQA 1147, Revised 04/2010 Page 17 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

12. EDUCATION: UNDERGRADUATE/GRADUATE/PROFESSIONAL EDUCATION – Starting with undergraduate education, LIST
ALL schools, colleges and universities attended, whether completed or not, in chronological order.

(College Name/Address) (Major/Minor Course of Study) (From: MM/DD/YY – To: MM/DD/YY) (Degree)

13. Have you ever been dropped, suspended, placed on probation, expelled or
requested to resign from any school, college or university? [ ] YES [ ] NO
(If „yes‟, explain on a separate sheet providing accurate details.)

14. POSTGRADUATE EDUCATION: List in chronological order all professional/postgraduate training (Internship/Residency/Fellowship).

(Program Name and full mailing address required) (Specialty Area) (From: MM/YY – To: MM/YY)

15. Have you ever been placed on probation, restrictions, suspension, revocation
modification, allowed to resign, requested to leave, temporarily or permanently
or otherwise acted against by a Chiropractic/Professional training program prior
to completion of training? [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation.)

16. List in chronological order from date of graduation from Chiropractic/Professional college all professional/postgraduate training
disciplinary actions to the present:

(Program Name and full mailing address required) (Institution/Hospital) From: MM/YY To: MM/YY

DH-MQA 1147, Revised 04/2010 Page 18 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

17. PRACTICE/EMPLOYMENT: List in chronological order from date of graduation to present, all practice employment, non-employment and/or any
unaccounted period of time. (use back of page)

(Name and full mailing address of Practice Setting) (Type of Employment) From: MM/YY To: MM/YY

18. Have you taught graduate medical education within the
last 10 years? [ ] YES [ ] NO

a. Do you currently hold a faculty appointment at a Chiropractic/health-related
institution of higher learning? [ ] YES [ ] NO
(If „yes‟, complete section 18b)

b. List any hospital/health institution/clinic/medical facility where you have faculty appointment:

___________________________________________________________________________________________________________
(Name and full mailing address of Institution) (Title of Appointment)

(Name and full mailing address of Institution) (Title of Appointment)

19. Do you currently hold staff privileges in any hospital, health institution, clinic or
medical facility? (If „yes‟, complete section 19a) [ ] YES [ ] NO

a. List any hospital/health institution/clinic/medical facility where you hold staff privileges (Do Not List Training Privileges).

(Name/mailing address of Facility) (Type of Privileges) (Chief of Staff) From: MM/YY To: MM/YY

b. Have you ever had any staff privileges denied, suspended, revoked, modified
restricted, placed on probation, asked to resign or asked to take a temporary
leave of absence or otherwise acted against by any facility? [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation)

(Name of Institution) (Date: MM/DD/YY) (Violation) (Final Action) (Under Appeal? Y/N)

DH-MQA 1147, Revised 04/2010 Page 19 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

c. Have you ever been asked, or allowed to resign from any facility in lieu of
disciplinary action or during any pending investigations into your practice? [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation)

(Name/Address of Facility) (Date: MM/DD/YY) (Violation/Investigation) (Reason for Resignation)

d. Have you ever had any staff privileges restricted or not renewed by any facility
in lieu of disciplinary action? [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation)

(Name/Address of Facility) (Date: MM/DD/YY) (Circumstances) (Final Action)

20. CERTIFICATION: Are you certified by any Specialty Board recognized by the
American Chiropractic Association or International Chiropractic Association? [ ] YES [ ] NO
(If „yes‟, list below and enclose a copy of each certification or letter of verification)

(Board Name) (Certification/Specialty/SubSpecialty) (Date of Certification)

a. Have you ever applied for, taken an examination for, or failed to receive
specialty board certification or recertification for any reason? [ ] YES [ ] NO
(If „yes‟, explain on a separate sheet, providing accurate details.)

b. Have you ever had any sanctions taken against you by a specialty board
recognized by the ACA, ICA, or other similar national organization? [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation.)

(Name of Specialty Board) (Date: MM/DD/YY) (Circumstances) (Final Action) (Under Appeal? Y/N)

ALL AFFIRMATIVE ANSWERS MUST BE EXPLAINED IN DETAIL ON A SEPARATE SHEET.
DOCUMENTATION SUBSTANTIATING THE EXPLANATION IS REQUIRED.

21. Have you had any application for professional license or any application
to practice Chiropractic Medicine denied by any state board or other
governmental agency of any state or country? [ ] YES [ ] NO

22. Have you ever been notified to appear before any licensing agency for a hearing
on a complaint of any nature including, but not limited to, a charge or violation
of the Chiropractic Medicine practice act, unprofessional or unethical conduct? [ ] YES [ ] NO

DH-MQA 1147, Revised 04/2010 Page 20 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

23. Have you ever had any professional license or license to practice Chiropractic
Medicine revoked, suspended, placed on probation, received a citation, or
other disciplinary action taken in any state, territory or country? [ ] YES [ ] NO
(If „yes‟ for questions 21-23, list below and see instructions for required documentation.)

(Name of Agency) (Date: MM/DD/YY) (Circumstances) (Final Action) (Under Appeal? Y/N)

24. Have you ever been convicted of, or entered a plea of guilty, nolo contendere,
or no contest to, a crime in any jurisdiction other than a minor traffic offense?
You must include all misdemeanors and felonies, even if adjudication was
withheld by the court so that you would not have a record of conviction.
Driving under the influence or driving while impaired is not a minor traffic
Offense for purposes of this question. [ ] YES [ ] NO
(If „yes‟, list below and see instructions for required documentation)

(Offense) (Date: MM/DD/YY) (Jurisdiction) (Final Action) (Under Appeal? Y/N)

25. Have you ever had employment terminated for cause? [ ] YES [ ] NO

26. Have you ever been arrested or criminally or civilly charged with any intentional or
negligent action related to use or misuse of drugs, alcohol, or illegal chemical
substances? [ ] YES [ ] NO

27. Have you ever been warned or called before the Drug Enforcement
Agency (DEA)? [ ] YES [ ] NO

28. Have you ever been made an offer to compromise or entered into any
other arrangement or other plea or agreement in lieu of a Federal
prosecution for a drug violation regulated by the DEA? [ ] YES [ ] NO

29. Have you ever been denied, or surrendered a DEA Registration? [ ] YES [ ] NO

Pursuant to Section 456.0635(2), Florida Statutes, the following questions are being asked. If you answer yes to any of
the following questions, explain on a separate sheet providing accurate details and submit copies of supporting
documentation.

30. Have you been convicted of, or entered a plea of guilty or nolo contendere to,
regardless of adjudication, a felony under Chapter 409, Chapter 817, or
Chapter 893, Florida Statutes; or 21 U.S.C. ss. 801-970 or 42 U.S.C. ss.1395-1396?
(If no, do not answer 31.) [ ] YES [ ] NO

31. Has it been more than 15 years prior to the date of this application since the
sentence and completion of any subsequent period of probation for each such conviction? [ ] YES [ ] NO

32. Have you ever been terminated for cause from the Florida Medicaid Program
pursuant to Section 409.913, Florida Statutes? (If no, do not answer 33.) [ ] YES [ ] NO

DH-MQA 1147, Revised 04/2010 Page 21 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

33. If you have been terminated but reinstated, have you been in good standing with
the Florida Medicaid Program for the most recent five years? [ ] YES [ ] NO

34. Have you ever been terminated for cause, pursuant to the appeals procedures
established by the state or federal government, from any other state Medicaid
program or the federal Medicare program? (If no, do not answer 35. and 36.) [ ] YES [ ] NO

35. Have you been in good standing with a state Medicaid program or the federal
Medicare program for the most recent five years? [ ] YES [ ] NO

36. Did the termination occur at least 20 years prior to the date of this application? [ ] YES [ ] NO

37. STATEMENT OF FINANCIAL RESPONSIBILITY: (READ ALL OPTIONS/CHECK APPROPRIATE CATEGORY)
PROVIDING FALSE INFORMATION MAY RESULT IN DISCIPLINARY ACTION OR CRIMINAL PENALTIES AS PROVIDED IN SECTIONS 456.066,
456.072, 775.082 AND/OR 755.083 AND/OR 755.084, FLORIDA STATUTES.

[ ] I hereby certify that I have applied for professional liability coverage in an amount of not less than $100,000 with the
following company ___________________________________ and a letter of confirmation from this company is being sent
to the board office. Upon being issued a license by this board, I will forward a copy of proof of my insurance.

[ ] I hereby certify that I have professional liability coverage in an amount of not less than $100,000 with the following company
_____________________________. (Proof of coverage must come directly from the company).

[ ] I hereby certify that I have an irrevocable letter of credit, established pursuant to Chapter 675, in an amount of not less than
$100,000 per claim.

[ ] I am exempt from demonstrating financial responsibility because I practice exclusively as an officer, employee or agent of the
federal government, or of the state or its agencies or subdivisions.

[ ] I am exempt from demonstrating financial responsibility because I practice only in conjunction with my teaching duties at an
accredited chiropractic medicine school/college or its main teaching hospital.

[ ] I am exempt from demonstrating financial responsibility because I do not practice in the State of Florida.
(Applicable to Students)

[ ] I am exempt from demonstrating financial responsibility because I have no malpractice exposure in the State of Florida.

38. LIABILITY CLAIMS:
a. Are you covered by an insurer required to report pursuant to s. 627.912 F.S.? [ ] YES [ ] NO

b. Have you been insured continuously during the last ten years? [ ] YES [ ] NO

c. Within the previous ten years have you had a liability claim or action for
damages for personal injury settled or finally adjudicated in an amount that
exceeds $5,000? [ ] YES [ ] NO

DH-MQA 1147, Revised 04/2010 Page 22 of 26
Rule 64B2-11.001, F.A.C.
NAME: ________________________________________________________________

Complete and attach a copy of EXHIBIT 1 for each occurrence. NOTE: Copies of reports previously submitted
may be re-submitted with this questionnaire to satisfy this reporting requirement.

EXHIBIT 1 – REPORT ON PROFESSIONAL LIABILITY CLAIMS AND ACTIONS
Include information relating to liability actions occurring within the previous 10 years. The actions are required to be reported under section 456.039 F.S. You must
submit a completed form for each occurrence.

Date of occurrence: ____/____/____ Date reported to licensee: ____/____/____

Injured person‟s name: (last, first, middle initial) ______________________________________________
Street Address: _________________________________________________________________________
City: __________________________________________ State: _______________ Zip Code: _________
Age: ________________ Sex: ______________

Date of suit: _____/_____/_____

List other defendants involved in this claim:
1. _________________________________________2._________________________________________
3. _________________________________________4._________________________________________

Date of final claim disposition: _____/_____/_____

Was there an itemized verdict? [ ]Yes [ ] No (If “YES”, attach copy of settlement verdict)

Indemnity paid on behalf of this defendant: $_______________
Loss adjustment expense paid to defense counsel: $_______________
All other loss adjustment expense paid: $_______________

Name of institution at which the injury occurred: ______________________________________________
Location of injury occurrence:
____Patient‟s Room ____Physical Therapy Dept. ____Radiology ____Labor & Delivery Room
____Operating Suite ____Nursery ____Emergency Room
____Special Procedure Room ____Recovery Room ____Critical Care Unit
____Other _____________________________________________

Final diagnosis for which treatment was sought or rendered. _____________________________________
______________________________________________________________________________________

Describe misdiagnosis made, if any, of the patient‟s actual condition. ______________________________
______________________________________________________________________________________

Describe the operation, diagnostic or treatment procedure causing the injury. Use nomenclature and/or descriptions of the procedures
used. Include method of anesthesia, or name of drug used for treatment, with detail of administration.
__________________________________________________________________
______________________________________________________________________________________

Describe the principal injury giving rise to the claim. Use nomenclature and/or descriptions of the injury. Include type of adverse
effect from drugs where applicable. ______________________________________
______________________________________________________________________________________

Safety management steps taken by the licensee to make similar occurrences less likely. ________________
______________________________________________________________________________________

I represent that these statements are true and correct pursuant to s. 837.06, Florida Statutes. I recognize that providing any false
statements made in writing with the intent to mislead the Department staff in the performance of their official duties, shall be
punishable as provided in s. 775.083 and 775.083, Florida Statute.

Signature of Physician: ___________________________________________________________________

DH-MQA 1147, Revised 04/2010 Page 23 of 26
Rule 64B2-11.001, F.A.C.
NAME: _________________________________________________________________

39. List all Chiropractic/Professional Society or Association Memberships:

___________________________________________________________________________________________________________
(Name of Society/Association) (Mailing Address) (Dates of Affiliation: From/To)

a. Have you ever had an application for membership denied by a
Chiropractic/Professional Society or Association? [ ] YES [ ] NO

b. Have you ever had a Chiropractic/Professional Society or Association
membership suspended? [ ] YES [ ] NO

c. Have you ever been notified to appear before a Chiropractic/Professional Society
or Association in regard to charges/complaints filed against you? [ ] YES [ ] NO
(If 'yes', complete section 20b and see instructions for required documentation)

d. List all Chiropractic/Professional Society or Association Membership Sanctions:

___________________________________________________________________________________________________________
(Name of Society/Association) (Full Mailing Address/for verification purposes) (Date of Action: MM/DD/YY)

40. OPTIONAL INFORMATION:

a. PUBLICATIONS: List any publications you have authored in peer-reviewed medical literature within the previous ten years.

___________________________________________________________________________________________________________
(Title) (Publication) (Date)

b. DO YOU PARTICIPATE IN THE MEDICAID PROGRAM? [ ] YES [ ] NO
If yes list:

_____________________________________________________
(Type of Provider)

c. PROFESSIONAL OR COMMUNITY SERVICE ACTIVITIES, HONORS OR AWARDS:

___________________________________________________________________________________________________________
(Activity/Honor/Award) (Organization)

DH-MQA 1147, Revised 04/2010 Page 24 of 26
Rule 64B2-11.001, F.A.C.
NAME: _________________________________________________________________

d. LANGUAGES OTHER THAN ENGLISH: Indicate languages other than English used by you to communicate with patients and
any translation service available for patients at your primary place of practice.

___________________________________________________________________________________________________________

e. COMMITTEES/MEMBERSHIPS: Indicate any committees on which you serve for any health entity with which you are
affiliated.

___________________________________________________________________________________________________________
(Name of Organization)

f. COMMENTS/ADDITIONAL INFORMATION: Any comments/information you want the board to be aware of.

___________________________________________________________________________________________________________

DH-MQA 1147, Revised 04/2010 Page 25 of 26
Rule 64B2-11.001, F.A.C.
NAME: _________________________________________________________________

41. APPLICANT SIGNATURE:

I understand that these statements are true and correct and recognize that providing false information may result in
disciplinary action against my license or criminal penalties pursuant to Sections 456.072, 460.413, 775.083 and 775.084, Florida
Statutes.
I hereby authorize all hospitals, institutions or organizations, my references, personal physicians, employers (past and
present) and all governmental agencies and instrumentalities (local, state, federal or foreign) to release to the Florida Board of
Chiropractic Medicine information which is material to my application for licensure.
I have carefully read the questions in the foregoing application and have answered them completely, without reservations
of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and
correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for
denial, suspension or revocation of my license to practice Chiropractic Medicine in the State of Florida.
I understand that my records are protected under the Federal and State Regulations governing Confidentiality of Mental
Health Patient Records and cannot be disclosed without my written consent unless otherwise provided in the regulations. I
understand that my records are protected under the Federal and State Regulations governing Confidentiality of Alcohol and
Drug Abuse Patient Records, 42CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided in
the regulations. I also state that I will comply with all requirements for licensure renewal in effect at the time of license
renewal including submission of appropriate renewal fees and continuing education requirements. I also understand that I
may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this
consent expires automatically as follows:

_______________________________________________________________________________________
(Specification of date, event or condition upon which this consent expires)

_______________________________________________________________________________________
(Signature of Applicant/required) (Date Signed/required)

*As a reminder to all applicants, please understand that Chapter 456.013(1)(a), Florida Statutes, provides that an incomplete
application shall expire one year after initial filing with the department.

Please make certified check or money order payable to the Department of Health. Return application and fees to:

Department of Health
Revenue Services
Post Office Box 6330
Tallahassee, Florida 32399-6330

Mail all supporting documents/correspondence to: (documents sent separate from application/no money)

Department of Health
Board of Chiropractic Medicine
4052 Bald Cypress Way, Bin #C07
Tallahassee, Florida 32399-3257

DH-MQA 1147, Revised 04/2010 Page 26 of 26
Rule 64B2-11.001, F.A.C.