Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (2022)

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (1)

South Carolina Department of Labor, Licensing and Regulation

South Carolina Board of Podiatry Examiners

110 Centerview Dr. Columbia SC 29210

P.O. Box 11289 Columbia SC 29211‐1289

Phone: 803‐896‐4500 MedBoard@llr.sc.gov• Fax:

8

INSTRUCTIONS AND REQUIREMENTS FOR LICENSURE AS A PODIATRIST

REQUIREMENTS

EDUCATION:

Completed at least three (3) years of pre-podiatry training at recognized college.

Received a diploma or certificate of graduation from a recognized college of podiatry medicine, which

has been accredited by the Council on Podiatric Medical Education.

EXAMS:

Parts I, II, & III of the National Board of Podiatry Examiners

“Par

t I, II & III (PMLexis) and Disciplinary reports should be ordered directly from the Federation of Podiatric Medical

Boards via their online system at https://www.fpmb.org

. Payment can be made with a credit card. Alternatively,

online orders can be printed and mailed to the FPMB with a check.”

In addi

tion to submitting or providing for submission of the documents as listed in the application package, an applicant

must also pass Part III of the National Board of Podiatry Examiners (formerly PMLexis). The PMLexis examination is

administered in June and December. Only applicants for licensure in South Carolina may take the PMLexis examination.

Please advise the Board if you plan to sit for the PMLexis in South Carolina.

If applying as a podiatrist who performs osseous (boney) surgical procedures of the ankle and related soft

tissue structures governing the ankle, you must submit:

1) copy of board certification or board qualification by the American Board of Foot and Ankle Surgery; and

2)

certification of graduation from a three-year residency program in podiatric medicine and reconstructive rear

foot and ankle (RRA) surgery accredited by the Council on Podiatric Medical Education.

Controlled Substance Registration

Application for both federal and state registration are available from the Narcotic and Drug Control Division,

Dept. of Health and Environmental control, 2600 Bull Street, Columbia, SC 29201, (803) 896-0634.

Lic

ensure for Podiatry Requirements and Instructions (2/19) Page 1 of 1

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (2)

Application to Practice Podiatry (2/20) Page 1 of 6

APPLICATION FOR A LICENSE TO PRACTICE PODIATRY

Include with your application:

Check or money order in the amount of $500 made payable to LLR-Board of Podiatry Examiners

Application fee is non-refundable. A returned check fee of up to $30, or an amount specified by

law, may be assessed on all returned funds.

Copy of your valid Driver’s License, State Issued ID, Passport or Military ID

Copy of your social security card

A 2”x2” professional photo that is notarized (Passport Photo)

Malpractice Claim Information Form, if applicable

Legal documentation for name change, if applicable

APMA Certification, if applicable

Certification of graduation from a 3 year residency in podiatric medicine and reconstructive rear foot and

ankle surgery (RRA), if applicable

Original, certified copy of your birth certificate

Preceptorship or residency certificate (one year completed)

Have submitted directly to the Board office address above from the issuing agent:

License Verification from each state podiatry board that you are currently or have ever been licensed in.

3 Letters of Recommendation from Podiatrists that know you on a professional basis

Parts I & II of National Boards

Graduate Transcript

Undergraduate college transcript

Copy of Podiatry Diploma

Note for SC Residents: To find your Congressional District you may go to: http://www.scstatehouse.gov/legislatorssearch.php

APPLICANT INFORMATION

Last Name: First: Middle: Suffix:

Have you ever legally changed your name? Yes No Former Name:

If yes, please submit legal documentation supporting the change. (Marriage certificate, divorce decree, etc.)

Home Address: City: State: Zip: District:

Congressional District (SC Residents Only)

Mailing Address: City: State: Zip:

(If different than above)

Phone: Email Address:

Business Name: Phone:

Fax: Email Address:

Date of Birth: Social Security No.:

Place of Birth (City, State or Country):

Race: Gender: Female Male

(For statistical purposes only)

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (3)

Application to Practice Podiatry (2/20) Page 2 of 6

PROFESSIONAL EDUCATION INFORMATION

List in chronological order from date of graduation all professional education. Do not include continuing

education coursework, apprentice, internship, residency, vocational training practical or clinical training. Attach

additional sheet(s) if needed

.

Institution/Program

LOCATION

(City and State or Country)

Attendance Dates

(

MM/YR MM/YR)

Graduation/Program

Completed?

Degree

Earned

INTERSHIP AND RESIDENCY TRAINING INFORMATION

Complete the requested information below on all training programs completed in the US or Canada. Failure to

disclose any training program information may result in the denial of your application or other appropriate

action. Attach an additional sheet if necessary.

School Name

LOCATION

(City and State or Country)

Attendance Dates

(MM/YR MM/YR)

Did you complete

program?

RECORD OF EXAMINATION

Complete the requested information below if licensure examination was taken in this state or any other state.

Name of Examination

LOCATION

(State or Country)

Date of Exam

Passed/Failed

Score

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (4)

Application to Practice Podiatry (2/20) Page 3 of 6

RECORD OF LICENSURE

List all states in which you have been licensed in for any medical profession; regardless of status: Active,

Inactive, Expired, Training etc. You will need to contact each State Board and request a License Verification

to be mailed directly to the Medical Board at the above listed address. We provide a License Verification Form

as a courtesy; however, we will accept a state board issued form. Attach additional sheet if needed.

State/Jurisdiction License No. State/Jurisdiction License No. State/Jurisdiction License No.

PODIATRY SPECIALTY AND SC LOCATION INFORMATION

1. What is your current podiatry specialty?

2. Proposed South Carolina Location Information (If known):

Name of Hospital/Clinic:

Complete Address:

3. Are you APMA Board certified/recertified? (If yes, attach a copy of the certificate) YES NO

If yes, date you were certified/recertified:

4. Are you board certified or board qualified by the American Board of Foot and Ankle

Surgery? (If yes, attach a copy of the certificate)

YES NO

5. Have you completed a three year residency in podiatric medicine and reconstructive

rear foot and ankle (RRA) surgery? (If yes, attach a copy of the certificate)

YES NO

PODIATRY PRACTICE EMPLOYMENT HISTORY

List all related employment (not training or residency) chronologically, most recent first, for the past five (5)

years. If you have never been employed in the profession you are applying for, insert N/A. Attach an additional

sheet if needed.

FROM

Month / Yr

TO

Month / Yr

EMPLOYER

NAME

OFFICE ADDRESS

TYPE OF

PRACTICE

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (5)

Application to Practice Podiatry (2/20) Page 4 of 6

PERSONAL HISTORY INFORMATION

If you answer yes to any of the below questions, you must attach a full written explanation.

1. Has your podiatry license ever been revoked, suspended, reprimanded, restricted,

disciplined, or placed on probation by a podiatric licensing board or other entity?

YES NO

2. Have you ever had an application to practice podiatry denied or refused by another

medical licensing board or other entity?

YES NO

3. Have you ever had any hospital or health care facility privileges denied, revoked,

suspended or restricted in any way?

YES NO

4. Have you ever voluntarily surrendered a medical license, controlled substance

registration or DEA registration?

YES NO

5. Have you ever resigned from any hospital, institution or health care facility in lieu

of disciplinary action?

YES NO

6. Are you currently under investigation or the subject of pending disciplinary action

by any podiatry licensing board, health care facility or other entity?

YES NO

7. Have you ever had a malpractice lawsuit, judgment filed against you or settled a

medical malpractice claim? If yes, how many? YES NO

(Complete a Malpractice Information Claim Form for each claim)

8. Are you currently being treated for any physical, mental or emotional condition

that might interfere with your ability to competently and safely perform the

essential functions of practice as a podiatrist?

YES NO

9. Do you currently have any mental illness (e.g. bipolar disorder, schizophrenia,

paranoia or any other psychotic disorder) or any physical illness or condition that

might interfere with your ability to competently and safely perform the essential

functions of practice

? YES NO

10. Within the past two (2) years, has your ability to practice podiatry been impaired

by any physical or mental illness or by the use of alcohol and/or drugs?

YES NO

11. Have you ever discontinued the practice of podiatry for any reason for three

consecutive months or more?

YES NO

12. Was your medical education / residency training interrupted other than for vacation

periods or military service? YES NO

13. Has your ability to prescribe controlled substances ever been denied, revoked,

suspended, or limited by any hospital, health care facility or other entity?

YES NO

14. Have you ever been convicted, pled guilty or pled nolo contendere to a felony

of any kind or to a non-felony crime involving drugs, fraud, deception,

sexual misconduct, gross immortality or unauthorized practice of podiatry?

YES NO

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (6)

Application to Practice Podiatry (2/20) Page 5 of 6

LETTERS OF RECOMMENDATION

Please supply below names and addresses of three podiatrists willing to write letters of recommendation to

support your application for South Carolina medical licensure. You must request that each podiatrist

listed below write directly to the Board indicating that you are known to them, in what capacity and for

how long, and outlining characteristics they believe qualify you for medical licensure in South Carolina.

The letters must be signed by the physician writing on your behalf. Make note of the reference number and

podiatrist’s name listed for when you check your application status later.

Reference 1.

Name: Phone:

Address:

Street, City, State, Zip

Reference 2.

Name: Phone:

Address:

Street, City, State, Zip

Reference 3.

Name: Phone:

Address:

Street, City, State, Zip

PRIVACY DISCLOSURE

South Carolina Law requires that every individual who applies for an occupational or professional license provide a

social security number for use in the establishment, enforcement and collection of child support obligations and for

reporting to certain databanks established by law. Failure to provide your social security number for these mandatory

purposes will result in the denial of your licensure application. Social security numbers may also be disclosed to other

governmental regulatory agencies and for identification purposes to testing providers and organizations involved in

professional regulation. Your social security number will not be released for any other purpose not provided for by law.

Other personal information collected by the Department for the licensing boards it administers is limited to such personal

information as is necessary to fulfill a legitimate public purpose. The South Carolina Freedom of Information Act ensures

that the public has a right to access appropriate records and information possessed by a government agency. Therefore,

some personal information on the application may be subject to public scrutiny or release. The Department collects and

disseminates personal information in compliance with The South Carolina Freedom of Information Act, the South

Carolina Family Privacy Protection Act, and other applicable privacy laws and regulations. Additionally, the Department

shares certain information on the application with other governmental agencies for various governmental purposes,

including research and statistical services.

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (7)

Application to Practice Podiatry (2/20) Page 6 of 6

CERTIFYING STATEMENT

I, ___________________________________________________ being duly sworn, depose and say that I am

the person described and identified, and that I am the person named in the documents presented in support of

this application. By filing this application, I hereby authorize and consent to an investigation of my fitness

and qualifications to practice podiatry in South Carolina.

I hereby authorize all hospitals, medical institutions or organizations, my references, personal physicians,

employers (past and present), and all governmental agencies and instrumentalities (local, state and federal) to

release to this licensing Board any information, files or records requested by the Board for its evaluation of

my professional, ethical and other qualifications for licensure in South Carolina. I hereby release, discharge

and exonerate the State Board of Podiatry Examiners of South Carolina, its agents or representatives and any

person or organization furnishing information from any and all liability of every nature and kind arising out

of the furnishing of documents, records or other information, or arising from the investigation made by the

State Board of Podiatry Examiners of South Carolina.

I have carefully read the questions in the foregoing application and have answered them completely, without

reservations of any kind, and I declare that all statements made by me herein are true and correct. Should I

furnish any false or incomplete information in this application, I hereby agree that such an act shall constitute

the cause for denial or revocation of my license to practice podiatry in South Carolina. Further, if licensed, I

agree to keep the Board informed of any future changes in my address.

Signature of Applicant

Print Name of Applicant

Subscribed and sworn to before me this ______ day

of _______________20 .

Notary Signature:

Print Name:

Notary for the State of:

My Commission expires:

(Notary Seal)

Tape a recent notarized

2 x 2

Passport Photo

(less than 6 months old)

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (8)

Rev: 02-02-2015

STATE OF SOUTH CAROLINA

DEPARTMENT OF LABOR, LICENSING AND REGULATION

VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES

AFFIDAVIT OF ELIGIBILITY

Pursuant to Section 8-29-10, et seq. of the South Carolina Code of Laws (1976, as amended), the Department

of Labor, Licensing and Regulation must verify that any person who applies for a South Carolina license is

lawfully present in the United States. Complete and sign this affidavit of eligibility. The information provided is

subject to verification.

Section A: LAWFUL PRESENCE in the United States.

The undersigned _ _____, of

_

_

(Print clearly First, Middle, and Last name) (Home Address, City, State, and Zip Code)

being first duly sworn deposes and states as follows:

Section B: ATTESTATION.

I understand that in accordance with section 8-29-10 of the South Carolina Code of Laws, a person who

knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall, in

addition to other sanctions imposed by this State or the United States, be guilty of a felony, and upon

conviction must be fined and/or imprisoned for not more than 5 years (or both).

I understand that the representations made in this Affidavit shall apply through any license(s) or renewals

issued, and that I shall have an affirmative duty to immediately advise the Department of Labor, Licensing and

Regulation of any change of my immigration or citizenship status.

I swear and attest the information contained herein is true and correct to the best of my knowledge. I

understand that under South Carolina law, providing false information is grounds for denial,

suspension, or revocation of a license, certificate, registration or permit.

Signature of Affiant

SWORN to before me this day of , 20

Notary Signature

Print Name

Notary Public for

My Commission Expires:

Check only one box:

1. I am a United States citizen; or

2.

I am a Legal Permanent Resident of the United States eighteen years of age or older; or

3.

I am a Qualified Alien or non-immigrant under the Federal Immigration and Nationality Act, Public Law

82-414, eighteen years of age or older, and lawfully present in the United States.

4.

Other:

Please submit any documentation that supports this status.

Date of Birth: _

Alien Number: _

I-94 Number:

(If you checked number 2, 3, or 4 you must attach a copy of your immigration documents. See

instruction sheet for a list of accepted immigration documents.)

Rev: 02-02-2015

INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY

CHECK box 1:

If you are a United States Citizen by birth or naturalization

CHECK box 2:

If you are a Legal Permanent Resident and you are not a U.S. Citizen, but are residing in the U.S. under legally

recognized and lawfully recorded permanent residence as an immigrant.

PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.

CHECK box 3:

If you are a Qualified Alien. You are a Qualified Alien if you are:

An alien who is lawfully admitted for residence under the INA.

An alien who is granted asylum under Section 208 of the INA.

A refugee who is admitted to the United States under Section 207 of the INA.

An alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year.

An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997)

or whose removal has been withheld under Section 241(b)(3).

An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1,

1980.

An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act

of 1980.

An alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or

subject to extreme cruelty.

PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.

ACCEPTED IMMIGRATION DOCUMENTS:

Unexpired Reentry Permit (I-327)

Permanent Resident Card or Alien Registration Receipt Card With Photograph (I-551)

Unexpired Refugee Travel Document (I-571)

Unexpired Employment Authorization Card Which Contains a Photograph (I-766)

Machine Readable Immigrant Visa (with Temporary I-551 Language)

Temporary I-551 Stamp (on passport or I-94)

I-94 (Arrival/Departure Record) in Unexpired Foreign Passport

I-20 (Certificate of Eligibility for Nonimmigrant, F-1, Student Status)

DS2019 (Certificate of Eligibility for Exchange Visitor, J-1, Status)

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (9)

Verification of Licensure Form (9/19) Page 1 of 1

VERIFICATION OF LICENSURE FORM

Use this form only if it is required by another state.

Complete the top portion of this form and forward a copy to each state board by which you are now or ever have

been licensed to practice medicine. You may want to contact each state to see if a fee is required.

Applicants Signature:

Print Name:

Address:

FOR STATE BOARD TO COMPLETE

This section to be completed by an official of the state board and returned directly to the South Carolina

Board of Medical Examiners. You may send a state issued license verification in lieu of this form.

Full name of licensee:

Graduate of: Date of Degree:

State of: License No.: Date Issued:

Is license current?

Yes

No If no, why not?

Has license been suspended, revoked, or restricted?

Yes

No If yes, why?

Comments, if any:

Date: Signature:

Print Name:

Board Seal

Title:

Board:

Free fillable Form 8: South Carolina Board of Podiatry Examiners (South Carolina Department of Labor, Licensing and Regulation) PDF form (10)

Medical Malpractice Form (8/19) Page 1 of 1

MALPRACTICE CLAIM INFORMATION

This form must be completed if you have ever been named as a defendant in a malpractice lawsuit, verdict or

settlement.

Physician Name Office Telephone No.

Address City State Zip

MALPRACTICE COMPLAINT:

Include name of patient, age, sex, date of occurrence and location, i.e., office or name and address of hospital.

Patient’s Name (not required):

Age: Sex: Date of Occurrence:

Place of Occurrence:

Indicate your position in case (i.e., resident, primary physician, etc.):

FILED AGAINST: ( ) Individual Doctor ( ) Group ( ) Hospital

List names of other defendant-doctors and/or hospitals:

DISPOSITION: ( ) Pending ( ) Jury Verdict ( ) Settled ( ) Dismissed ( ) Dropped

If there has been a verdict or settlement, please provide the following information:

Legal outcome:

Total amount paid (if any): Date paid:

Amount attributable to you:

1. On a separate sheet, provide a detailed written explanation of the background and medical issues involved in the case.

2. Attach copies of the complaint, answer, release, settlement documents and all other relevant legal documents.

3. Form may be duplicated as needed. A separate report must be completed for each malpractice claim.

Date: ________________________ Signature: ________________________________________________

•License Verification from each state podiatry board that you are currently or have ever been licensed in.. Complete the requested information below if licensure examination was taken inthis state or any other state.. release to this licensing Board any information, files or records requested by the Board for its evaluation of. State Board of Podiatry Examiners of South Carolina.. This section to be completed by an official of the state board and returned directly to the South Carolina

Official License Verification from another state. currently licensed in and have a License Verification mailed directly to our office (only one (1) active license verification is needed).. South Carolina Law requires that every individual who applies for an occupational or professional license provide a. disseminates personal information in compliance with The South Carolina Freedom of Information Act, the South. addition to other sanctions imposed by this State orthe United States,be guiltyofa felony, and upon

With the three difficulty levels — Normal, Nightmare, and Hell — you get three stat and skill resets from Akara for free.. Be sure to take back your gear before swapping mercenaries.. Gold is always important in Diablo 2: Resurrected.. While you receive skill points when you level up or complete certain quests, the next best way to get a boost to your skills is via gear.. A death in Diablo 2: Resurrected sends you back to the starting area of the Act without any of your gear.. Or, if you can't make it back, you can exit the game to move your body back to town.. Some people will swap out legendary items with low-end items that look the same, hoping people don't check the stat screen.

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