Massage Therapist Licensure Application

Transcription

1 Flrida Bard f Massage Therapy PO Bx 6330 Tallahassee, FL Web: inf@flridasmassagetherapy.gv Massage Therapist Licensure Applicatin Fees must be paid in the frm f a cashier s check r mney rder, made payable t: Department f Health Chse yur applicatin type: Massage Therapist by Exam (X-1021) $ Massage Therapist by Endrsement (X-1022) $ An applicant, wh is denied licensure, r withdraws the applicatin prir t licensure, is entitled t a refund f $ (initial licensure fee and unlicensed activity fee). A request t withdraw and/r receive a refund must be made in writing. Fees are refundable fr up t 3 years frm the date f receipt. 1. PERSONAL INFORMATION Name: Date f Birth: Last/Surname First Middle MM/DD/YYYY Mailing Address: (The address where mail and yur license shuld be sent.) Street/ PO Bx Suite/Apt. N City State Zip Cuntry Hme/ Cell Number Physical Lcatin: (Required if mailing address is a PO Bx. This address will be psted n the Department f Health s website.) Street/ PO Bx Suite/Apt. N City State Zip Cuntry Wrk/ Cell Number Equal Opprtunity Data: We are required t ask that yu furnish the fllwing infrmatin as part f yur vluntary cmpliance with Sectin 2, Unifrm Guidelines n Emplyee Selectin Prcedure (1978) 43 CFR38296 (August 25, 1978). This infrmatin is gathered fr statistical and reprting purpses nly and des nt in any way affect yur candidacy fr licensure. SEX: Male Female RACE: White Black Asian/Pacific Islander Hispanic Other Ntificatin: If yu want t be ntified f the status f yur applicatin by , please check the "Yes" bx and write yur address n the line prvided belw. If yu chse this frm f ntificatin, yu will receive infrmatin regarding yur applicatin file thrugh . Yu will be respnsible fr checking yur regularly and updating yur address with the Bard ffice at: inf@flridasmassagetherapy.gv I want t be ntified by Address: Yes N Under Flrida law, addresses are public recrds. If yu d nt want yur address released in respnse t a public recrds request, d nt prvide an address r send electrnic mail t ur ffice. Instead cntact the ffice by phne r in writing. DH-MQA 1115, 1/14 Page 1 f 10

2 2. MASSAGE THERAPY EDUCATION HISTORY NAME A. MASSAGE THERAPY SCHOOL GRADUATED FROM: Street City State Cuntry B. Date Graduated/ Anticipated Graduatin: MM/DD/YYYY C. ADDITIONAL MASSAGE THERAPY PROGRAM ATTENDED: D. Date Graduated/ Anticipated Graduatin: MM/DD/YYYY E. I authrize the schl(s) listed abve t release my fficial transcript(s) directly t the Flrida Bard f Massage Therapy. Yes N 3. APPLICANT BACKGROUND Attach additinal sheets, if necessary A. List any ther name(s) by which yu have been knwn in the past. B. List all health related licenses yu have ever held (active, inactive r lapsed). State/Cuntry Prfessin License N. Date Of Licensure 4. MANDATORY FLORIDA EDUCATION REQUIREMENT Cmpletin f a tw (2) hur curse n Preventin f Medical Errrs, a ten (10) hur curse n Flrida Laws and Rules and a three (3) hur curse n HIV/AIDS is required prir t licensure. These curses must be frm an apprved Flrida Bard f Massage Therapy prvider r massage schl. (If yu graduated frm a Flrida apprved massage schl yu may check Yes.) I attest I have cmpleted the required curses listed abve. Yes N If yu checked NO, please submit yur curse certificates t the Bard ffice upn cmpletin. 5. DISCIPLINARY HISTORY If yu answer yes t any f the questins in this sectin, yu are required t send the fllwing items: Self Explanatin, describing in detail the circumstances surrunding the disciplinary actin. A cpy f the Administrative Cmplaint and Final Order. Three (3) current (written within the last year) prfessinal Letters f Recmmendatin. Failure t disclse infrmatin in this sectin may result in a denial f yur applicatin. A. Yes N Have yu ever been denied r is there nw any prceeding t deny yur applicatin fr any healthcare license t practice in Flrida r any ther state, jurisdictin r cuntry? B. Yes N Have yu ever had disciplinary actin taken against yur license t practice any healthcare related prfessin by the licensing authrity in Flrida r in any ther state, jurisdictin r cuntry? C. Yes N Have yu ever surrendered a license t practice any healthcare related prfessin in Flrida r in any ther state, jurisdictin r cuntry while any such disciplinary charges were pending against yu? D. Yes N D yu have any disciplinary actin pending against yur license? DH-MQA 1115, 1/14 Page 2 f 10

3 NAME 6. CRIMINAL HISTORY Answers t cmmnly asked questins can be fund n ur website at: If yu answer Yes t any f the questins in this sectin, yu are required t send the fllwing items: Self Explanatin describing in detail the circumstances surrunding each ffense; including dates, city and state, charges and final results. Final Dispsitins and Arrest Recrds fr all ffenses. The Clerk f the Curt in the arresting jurisdictin will prvide yu with these dcuments. Unavailability f these dcuments must cme in the frm f a letter frm the Clerk f the Curt. Cmpletin f Sentence Dcuments. Yu may btain dcument frm the Department f Crrectins. The reprt must include the start date, end date and that the cnditins were met. Three (3) current (written within the last year) prfessinal Letters f Recmmendatin. A. Yes N Have yu EVER been cnvicted f, r entered a plea f guilty, nl cntendere, r n cntest t, a crime in any jurisdictin ther than a minr traffic ffense? Yu must include all misdemeanrs and felnies, even if adjudicatin was withheld. Reckless driving, driving while license suspended r revked (DWLSR), driving under the influence (DUI) r driving while impaired (DWI) are nt minr traffic ffenses fr purpses f this questin. B. Yes N Have charges ever been brught against yu by any branch f the United States Armed Services Failure t disclse infrmatin in this sectin may result in a denial f yur applicatin. 7. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS Applicants fr licensure, certificatin r registratin and candidates fr examinatin may be excluded frm licensure, certificatin r registratin if their felny cnvictin falls int certain timeframes as established in Sectin (2), Flrida Statutes. If yu answer Yes t any f the fllwing questins, please prvide a written explanatin fr each questin including the cunty and state f each terminatin r cnvictin, date f each terminatin r cnvictin, and cpies f supprting dcumentatin t the address belw. Supprting dcumentatin includes curt dispsitins r agency rders where applicable. 1. Yes N Have yu been cnvicted f, r entered a plea f guilty r nl cntendere t, regardless f adjudicatin, a felny under Chapter 409, F.S. (relating t scial and ecnmic assistance), Chapter 817, F.S. (relating t fraudulent practices), Chapter 893, F.S. (relating t drug abuse preventin and cntrl) r a similar felny ffense(s) in anther state r jurisdictin? If yu respnded N t the questin abve, skip t questin 2. a. Yes N If Yes t 1, have yu successfully cmpleted a drug curt prgram fr a felny ffense that resulted in the plea being withdrawn r charges dismissed? b. Yes N If Yes t 1, fr felnies f the first r secnd degree, has it been mre than 15 years befre the date f applicatin? c. Yes N If Yes t 1, fr felnies f the third degree, has it been mre than 10 years befre the date f applicatin, except fr felnies f the third degree under Sectin (6), Flrida Statutes? d. Yes N If Yes t 1, fr felnies f the third degree under Sectin (6)(a), Flrida Statutes, has it been mre than 5 years befre the date f applicatin? DH-MQA 1115, 1/14 Page 3 f 10

4 2. Yes N Have yu been cnvicted f, r entered a plea f guilty r nl cntendere t, regardless f adjudicatin, a felny under 21 U.S.C. ss (relating t cntrlled substances) r 42 U.S.C. ss (relating t public health, welfare, Medicare and Medicaid issues)? If yu respnded N t the questin abve, skip t questin 3. NAME a. Yes N If Yes t 2, has it been mre than 15 years befre the date f applicatin since the sentence and any subsequent perid f prbatin fr such cnvictin r plea ended? 3. Yes N Have yu ever been terminated fr cause frm the Flrida Medicaid Prgram pursuant t Sectin , Flrida Statutes? If yu respnded N t the questin abve, skip t questin 4. a. Yes N If yu have been terminated but reinstated, have yu been in gd standing with the Flrida Medicaid Prgram fr the mst recent five years? 4. Yes N Have yu ever been terminated fr cause, pursuant t the appeals prcedures established by the state, frm any ther state Medicaid Prgram? If yu respnded N t the questin abve, skip t questin 5. a. Yes N Have yu been in gd standing with a state Medicaid prgram fr the mst recent five years? b. Yes N Did the terminatin ccur at least 20 years befre the date f this applicatin? 5. Yes N Are yu currently listed n the United States Department f Health and Human Services Office f Inspectr General s List f Excluded Individuals and Entities? 6. Yes N If Yes t any f the questins 1 thrugh 5 abve, n r befre July 1, 2009, were yu enrlled in an educatinal r training prgram in the prfessin in which yu are seeking licensure that was recgnized by the Bard f Massage Therapy r Department f Health? (If Yes, please prvide fficial dcumentatin verifying yur enrllment status.) 8. EXAMINATION HISTORY Please indicate which f the fllwing licensure examinatins yu have passed Name f Examinatin State/Cuntry Mnth/Year NCBTMB NCETM NESL MBLEX Other: 9. ADDITIONAL INFORMATION Yes N Availability fr Disaster: Will yu be available t prvide health care services in special needs shelters r t help staff disaster medical assistance teams during times f emergency r majr disaster? DH-MQA 1115, 1/14 Page 4 f 10

5 NAME CONFIDENTIAL AND EXEMPT FROM PUBLIC RECORDS DISCLOSURE* 10. HEALTH HISTORY (Supprting dcumentatin shuld be sent directly t the bard ffice) If yu answer Yes t any f the questins in this sectin, yu are required t send the fllwing items: Self Explanatin, explaining the medical cnditin(s) r ccurrence(s) and current status. Letter(s) frm Licensed Prfessinal summarizing diagnsis, treatment and prgnsis; r any ther fficial dcumentatin as it relates t any Yes answer. Dcumentatin must be current within the last year. A. Yes N In the last five years, have yu been enrlled in, required t enter int, r participated in any drug r alchl recvery prgram r impaired practitiner prgram fr treatment f drug r alchl abuse that ccurred within the past five years? B. Yes N In the last five years, have yu been admitted r referred t a hspital, facility r impaired practitiner prgram fr treatment f a diagnsed mental disrder r impairment? C. Yes N During the last five years, have yu been treated fr r had a recurrence f a diagnsed mental disrder that has impaired yur ability t practice massage therapy within the past five years? D. Yes N During the last five years, have yu been treated fr r had a recurrence f a diagnsed physical disrder that has impaired yur ability t practice massage therapy? E. Yes N In the last five years, were yu admitted r directed int a prgram fr the treatment f a diagnsed substance-related (alchl/drug) disrder r, if yu were previusly in such a prgram, did yu suffer a relapse within the last five years? F. Yes N During the last five years, have yu been treated fr r had a recurrence f a diagnsed substance-related (alchl/drug) disrder that has impaired yur ability t practice massage therapy within the past five years? Name: Last First Middle Scial Security Number: * This page is exempt frm public recrds disclsure. The Department f Health is required and authrized t cllect Scial Security Numbers relating t applicatins fr prfessinal licensure pursuant t Title 42 USCA 666 (a)(13). Fr all prfessins regulated under Chapter 456, Flrida Statutes, the cllectin f Scial Security Numbers is required by sectin (1)(a), Flrida Statutes. Scial Security Infrmatin - * Under the Federal Privacy Act, disclsure f Scial Security numbers is vluntary unless specifically required by federal statute. In this instance, Scial Security numbers are mandatry pursuant t Title 42 United States Cde, Sectins 653 and 654; and Sectin (1), and , Flrida Statutes. Scial Security numbers are used t allw efficient screening f applicants and licensees by a Title IV-D child supprt agency t ensure cmpliance with child supprt bligatins. Scial Security numbers must als be recrded n all prfessinal and ccupatinal license applicatins and will be used fr license identificatin pursuant t the Persnal Respnsibility and Wrk Opprtunity Recnciliatin Act f 1996 (Welfare Refrm Act. 104 Pub.L. Sectin 317) Clarificatin f the SSA prcess may be reviewed at r by calling DH-MQA 1115, 1/14 Page 5 f 10

6 NAME I understand that it is my duty and respnsibility as an applicant fr licensure t supplement my applicatin after it has been submitted if and when any material change in circumstances r cnditins ccur which might affect the Bard s decisin cncerning my eligibility fr examinatin r licensure. Such supplement is required by sectin (1), F.S. Failure t d s may result in disciplinary actin by the Bard including denial f licensure. I have carefully read the questins in the freging applicatin and have answered them cmpletely, withut reservatin f any kind, and I declare that my answers and all statements made by me herein and in supprt f this applicatin are true and crrect. Shuld I furnish any false infrmatin n r in supprt f this applicatin, I understand that such actin shall cnstitute cause fr denial, suspensin, r revcatin f any license t practice in the state f Flrida in the prfessin fr which I am applying. I hereby acknwledge that practice as a licensed Massage Therapist in Flrida is gverned by Chapters 456 and 480, F.S., and Rule Chapter 64B7, F.A.C. I understand that I am under a cntinuing bligatin t understand and keep infrmed f any changes t Chapters 456 and 480, F.S., and Rule Chapter 64B7, F.A.C. Applicant Signature: This field cannt be typed. Yu must print the applicatin and sign it. Date: MM/DD/YYYY All applicatins filed with the department are valid fr ne (1) year frm the date f receipt. DH-MQA 1115, 1/14 Page 6 f 10

7 FLORIDA BOARD OF MASSAGE THERAPY LICENSE VERIFICATION REQUEST After cmpletin f this frm, please frward this frm t the licensing agency f each state by which yu are nw r have been licensed. Applicant Name: SSN: Address: Name riginal license was issued under: License Number: State: I hereby authrize release f any infrmatin regarding my licensure status t the Flrida Bard f Massage Therapy. Applicant Signature: Date: STATE LICENSING AGENCY All verificatins shall be cmpleted in English and mailed r sent electrnically directly frm the state(s) r jurisdictin(s) and must include the fllwing criteria: Typed n an fficial state frm r letterhead Include an fficial Bard seal Signature and title f state Bard fficial The fllwing infrmatin must be included in all verificatins: Licensee name License number State r jurisdictin f licensure Dates f issuance/expiratin Licensure methd; exam type r endrsement Licensure status Is license in gd standing? Has this license ever been encumbered (denied, revked, suspended surrendered, limited, placed n prbatin)? Cmplete verificatins must be mailed r sent electrnically directly frm the state licensure Bard t: Flrida Bard f Massage Therapy 4052 Bald Cypress Way Bin C-06 Tallahassee, FL Fax (850) inf@flridasmassagetherapy.gv DH-MQA 1115, 1/14 Page 7 f 10

8 CRIMINAL CONVICTION SELF EXPLANATION FORM This frm must be cmpleted if yu answer YES t any f the criminal histry questins n the applicatin. Please cmplete a separate frm fr EACH ffense. Duplicate this frm as necessary. Name: Scial Security Number: Level f Offense (Circle One): Felny Misdemeanr Lcatin f Occurrence: City State Date f Offense: Date f Sentencing: Offense Type (DUI, Battery, Prstitutin, etc.): Explanatin/details surrunding the ffense: What happened? What changes have yu made? Attach additinal sheets as necessary. Sentencing Infrmatin: Please list the details f yur sentencing (I.e.: prbatin, jail time, fines/csts, prgrams cmpleted, etc.) Current Dispsitin: Please list the current dispsitin f yur sentencing. Dn t frget t attach dcumentatin frm the Clerk f Curt pertaining t the arrest/charges, sentencing due t the arrest and prf f successful cmpletin f yur sentencing. DH-MQA 1115, 1/14 Page 8 f 10

9 Flrida Bard f Massage Therapy Transcript Request Frm If yu graduated frm a massage therapy prgram apprved by a state ther than Flrida, cmplete the tp sectin and send this frm t yur Massage Therapy schl t cmplete and attach yur transcripts. NAME ADDRESS SOCIAL SECURITY # DATE OF BIRTH I authrize the schl t release the infrmatin requested belw t the Flrida Bard f Massage Therapy. Signature f Student: Date: MM/DD/YYYY This sectin is t be cmpleted by the Dean, Registrar, r Chairpersn f the massage therapy prgram at the United States schl frm which the applicant graduated. DO NOT cmplete this frm in anticipatin f prgram cmpletin. I hereby certify that successfully cmpleted a Massage Name f Applicant Therapy educatin prgram at n Schl Name MM/DD/YYYY Street Address State Zip Cde The curriculum cmpleted by Applicant equals r exceeds the curriculum requirements set frth in rule chapter 64B F.A.C. (Attached) Hurs cmpleted: The schl must be apprved by a gvernmental agency authrized t apprve massage therapy prgrams. Name f apprving agency License/certificate number Printed name f Dean/Registrar/Chairpersn f M.T. Prgram Date Signature RETURN THE ORIGINAL COMPLETED FORM, OFFICIAL STUDENT TRANSCRIPTS, AND PROOF OF SCHOOL APPROVAL DIRECTLY TO THE BOARD OFFICE. Please mail t: Flrida Bard f Massage Therapy, 4052 Bald Cypress Way, Bin C06, Tallahassee, FL DH-MQA 1115, 1/14 Page 9 f 10

10 64B , F.A.C. Minimum Requirements fr Bard Apprved Massage Schls. (1) In rder t receive and maintain Bard f Massage Therapy apprval, a massage schl, and any satellite lcatin f a previusly apprved schl, must: (a) Meet the requirements f and be licensed by the Department f Educatin pursuant t Chapter 1005, F.S., r the equivalent licensing authrity f anther state r cunty, r be within the public schl system f the State f Flrida; and (b) Offer a curse f study that includes, at a minimum, the 500 classrm hurs listed belw, cmpleted at the rate f n mre than 6 classrm hurs per day and n mre than 30 classrm hurs per calendar week: Curse f Study Classrm Hurs Anatmy and Physilgy 150 Basic Massage Thery and Histry 100 Clinical Practicum 125 Allied Mdalities 76 Business 15 Thery and Practice f Hydrtherapy 15 Flrida Laws and Rules 10 (Chapters 456 and 480, F.S. and Chapter 64B7, F.A.C.) Prfessinal Ethics 4 HIV/AIDS Educatin 3 Medical Errrs 2 DH-MQA 1115, 1/14 Page 10 f 10