OFFICIAL NOTICE  

DO NOT WRITE IN THIS SPACE

License Number                  Expiration Date
________________            _________________ 		  Fee Received __________________ 20 ______
$470.00 Renewal fee if received at Board office on or
                before November 1, 2011.
$702.00 Renewal fee plus late fee if received at Board
                office 1-90 days after expiration date.
$934.00 Renewal fee plus last fee if received at Board
                office more than 90 days after expiration date. 		  Renewal Certificate No. __________________
  Issued _______________________ 20 ______
  Check Number _________________________
  Amount ______________________________
 

PLEASE PRINT OR TYPE ALL INFORMATION
 
NAME: ________________________________________________________________________
                        First                                                        Middle                                                Last
MAILING ADDRESS:   ___________________________________________________________
  ___________________________________________________________
PHONE:   ___________________________________________________________
FAX:   ___________________________________________________________
E-MAIL   ___________________________________________________________
COUNTY   ___________________________________________________________
 
Since the last renewal, have you been convicted, given probation (whether deferred or not), fined or has a criminal indictment or information been filed against you for a felony or misdemeanor involving moral turpitude or other crime?                                   Yes __________          No __________
 
Since the last renewal, have you been sued for medical malpractice or other private civil action alleging medical malpractice?                           Yes __________          No __________
 
If you answered "Yes" to the above questions, please provide full details of the matters in an attachment to this application. Include case, title, cause number, date filed, and court.
 
NOTICE
  1. Please remit payment along with this form to the address listed at end of form;
  2. Annual License Renewal Certificates must be secured on or before the first day of NOVEMBER of each year;
  3. Board office must be kept informed of any address and/or telephone number changes (see §375.27 of the TSBPME Rules for penalties)
  4. License and Annual Renewal Certificate must be displayed in office where licensee practices;
  5. CME hours must be current in order to renew license. The Board will conduct random audits of CME documentation to ensure compliance. DO NOT SEND ANY CME's TO BOARD UNLESS REQUESTED.
  6. We strongly encourage all licensees to renew their licenses online at www.TexasOnline.com or www.foot.state.tx.us

List all office addresses, phone numbers and fax numbers: (Attach an additional sheet if necessary)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
 
Are all your patient service areas accessible to disabled persons as defined by federal law?
                                                          Yes __________          No __________
 
Describe any language translating services (Spanish, hearing impairment, etc.) that you provide for your patients:  _________________________________________________________________________
 
What insurance plans do you accept, including participation in the State Child Health Plan under Chapter 62 of the Health & Safety Code, or the Medicaid program: Please list your top 11.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Please list any education and training you have received (College degrees, advanced degrees/training, completion of residency program(s), etc):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
 
What specialty certifications do you have and what specialty boards do you belong to:
_________________________________________________________________________________
_________________________________________________________________________________
 
In what states have you practiced podiatric medicine and for how many years in each:
_________________________________________________________________________________
 
Please list all hospitals and other locations at which you have surgical privileges:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
 
Home Address, Phone and Fax:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
 
Work E-Mail Address:  _______________________________________________________________
 
Federal Employers Identification Number (FEIN):         ________________________________________
 
Drug Enforcement Administration (DEA) Number(s):   ________________________________________
 
Medicare Provider/Supplier Identification Number(s):    ________________________________________
 
Medicaid Provider/Supplier Identification Number(s):     ________________________________________
 
Unique Physician Identification (UPIN) Number(s):      ________________________________________
 
National Provider Identification (NPI) Number(s):         ________________________________________
Do you have demonstrated experience in Worker's Compensation or Utilization Reviews?    Yes___No___

REQUIRED CME AFFIRMATION
This affirmation must be signed and dated by you only if you were licensed in an ODD numbered year. If so, you must have obtained 50 hours of approved CME's before your license will be renewed. If this affirmation is not signed, your license will not be renewed and your renewal form will be returned to you as "incomplete".
On ______________________ I, _____________________________________________, D.P.M.,
              (Today's Date)                                              (Sign Your Name Above)
do hereby attest and affirm that I have obtained the required 50 hours of approved CME's that are required by Board Rules to renew my license to practice podiatric medicine in Texas.

I certify that the information I have provided on this application is true and correct. I understand it is a criminal violation (Penal Code, Sec. 37.10) to submit a false statement to a governmental agency. I understand that practicing with a Delinquent or Cancelled license can result in the loss of clinical privileges and severe administrative and criminal penalties.

Signature _______________________________________________     Date ____________________

Texas State Board of Podiatric Medical Examiners
Mailing Address: P.O. Box 12216, Austin, TX 78711-2216
Physical Address: 333 Guadalupe Street, Suite #2-320, Austin, TX 78701
Phone: (512)-305-7000 Fax: (512)-305-7003
Website: www.foot.state.tx.us