Florida

Board

of

Chiropractic Medicine

If a “Yes” response is provided to any of the questions in the health history section, provide the following documents directly to the board office:

A letter from a Licensed Health Care Practitioner, who is qualified by skill and training to address the condition identified, which explains the impact the condition may have on the ability to practice the profession with reasonable skill and safety. The letter must specify that the applicant is safe to practice the profession without restrictions or specifically indicate the restrictions that are necessary. Documentation provided must be dated within one year of the application date.

A written self-explanation, identifying the medical condition(s) or occurrence(s); and current status.

Applicants with prior disciplinary actions are required to submit the following:

Board Actions – Certified copies of document(s) relative to any disciplinary action taken against any license. The documents must come from the agency that took the disciplinary action and must be certified by that agency.

Self-Explanation – A detailed description of the circumstances surrounding your disciplinary action and a thorough description of the rehabilitative changes in your lifestyle since the time of the disciplinary action which would enable you to avoid future occurrences. It would be helpful to include factors in your life, which you feel may have contributed to your disciplinary action, what you have learned about yourself since that time, and the changes you have made that support your rehabilitation.

Applicants with prior criminal convictions are required to submit the following:

Final Dispositions/Arrest Records – Final disposition records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the clerk of the court attesting to their unavailability.

Completion of Probation/Parole/Sanctions – Probation and financial sanction records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. Parole records for offenses can be obtained from the Department of Corrections or at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the clerk of the court attesting to their unavailability.

Self-Explanation – Applicants who have listed offenses on the application must submit a letter in their own words describing the circumstances of the offense. Include in your letter the date of the original offense, the charge, and the jurisdiction where it occurred.

Effective January 1, 2013, applicants for initial licensure must use an approved Livescan Service Provider to submit electronic fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to applicant. The results of the search will be returned to the Care Provider Background Screening Clearinghouse and made available to the Department for consideration during the licensure process. The fingerprints submitted by the applicant will be retained by FDLE and the Clearinghouse. All costs for conducting a criminal history background screening are borne by the applicant.

It is important to use the correct Originating Agency Identification (ORI) when submitting fingerprints. If you do not provide an ORI number or if you provide an incorrect ORI number to the Livescan service provider, the board office will not receive your fingerprint results.

The ORI number for the Board of Chiropractic Medicine is EDOH2016Z.

The applicant is fully responsible for selecting an approved Livescan Service Provider and for ensuring the results are reported to the Department. Print this electronic fingerprinting form and take it with you to a Livescan Service Provider.

For more information, FAQs, and a list of all approved Livescan Service Providers please visit the Background Screening website: https://www.flhealthsource.gov/background-screening/ (Click on Locate a Provider)

Effective July 1, 2012, Section 456.0635, Florida Statutes (F.S.), provides that health care boards or the department shall refuse to issue a license, certificate or registration and shall refuse to admit a candidate for examination if the applicant:

1. Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, F.S., (relating to social and economic assistance), Chapter 817, F.S., (relating to fraudulent practices), Chapter 893, F.S., (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction unless the candidate or applicant has successfully completed a drug court program for that felony and provides proof that the plea has been withdrawn or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, or registration, unless the sentence and any subsequent period of probation for such conviction or plea ended:
   1. For the felonies of the first or second degree, more than 15 years from the date of the plea, sentence and completion of any subsequent probation;
   2. For the felonies of the third degree, more than 10 years from the date of the plea, sentence and completion of any subsequent probation;
   3. For the felonies of the third degree under section 893.13(6)(a), F.S., more than five years from the date of the plea, sentence and completion of any subsequent probation;
2. Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues), unless the sentence and any subsequent period of probation for such conviction or pleas ended more than 15 years prior to the date of the application;
3. Has been terminated for cause from the Florida Medicaid program pursuant to section 409.913, F.S., unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent five years;
4. Has been terminated for cause, pursuant to the appeals procedures established by the state or Federal Government, from any other state Medicaid program, unless the candidate or applicant has been in good standing with a state Medicaid program for the most recent five years and the termination occurred at least 20 years before the date of the application;
5. Is currently listed on the United States Department of Health and Human Services Office of Inspector General’s List of Excluded Individuals and Entities.