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Janice K. Brewer Governor

ARIZONA STATE BOARD OF PHYSICAL THERAPY

4205 N. 7th Ave, Ste 208 Phoenix, Arizona 85013 Telephone (602) 274-0236 web: www.ptboard.az.gov

Charles D. Brown Executive Director

PHYSICAL THERAPIST

REINSTATEMENT OF ADMINISTRATIVELY SUSPENDED LICENSE AND LICENSE RENEWAL

September 1, 2010 through August 31, 2012 Your Arizona physical therapist license has been administratively suspended. In accordance with Arizona Revised Statute §32-2027 you may not practice as a physical therapist until your license has been reinstated and renewed. Practicing with an administratively suspended license is a violation of A.R.S. §32-2048 and may result in disciplinary action by the Board pursuant to A.R.S. §32-2044. In addition the following applies: All reinstated licensees are subject to an audit for completion of the required continuing competence hours described in the Arizona Administrative Code Title 4, Chapter 24, Article 4. If your license was administratively suspended on 8/31/2010 AND you received your license on or before 08/31/09 pursuant to R4-24-401 through R4-24-403 you are required to obtain 20 contact hours of continuing competence activities. At least 10 hours, up to the full amount, must come from Category A activities; up to 5 contact hours may come from Category B and up to 5 contact hours may come from Category C. You must submit the attached Audit form and documentation of this requirement with this Reinstatement form. If your license was administratively suspended on 8/31/2010, AND you received your license between 09/01/09 and 08/31/10 pursuant to R4-24-401 through R4-24-403 you are required to obtain 10 contact hours of continuing competence activities. All 10 hours must come from Category A. You must submit the attached Audit form and documentation of this requirement with this Reinstatement form. If your license was administratively suspended 3 or more years ago, you must reapply for licensure as a new applicant. **If you HAVE practiced in Arizona with an administratively suspended license you must submit the following: 1. Application for reinstatement and renewal, 2. Fee of $260.00 ($100 reinstatement fee and $160 renewal fee), 3. Separate affirmation acknowledging the dates during which you practiced with an administratively suspended license (form attached), 4. Arizona Statement of Citizenship and Alien Status for Public Benefits form, if you have not previously submitted the form with proof of status (form attached), 5. Audit form and documentation of continuing competence hours (form attached). If you practiced with an administratively suspended license the Board will review your application at a public meeting to determine possible violations of law and disciplinary action. **If you HAVE NOT practiced with an administratively suspended license, you must submit the following: 1. Application for reinstatement and renewal, 2. Fee of $260.00 ($100 reinstatement fee and $160 renewal fee), 3. Separate affirmation stating that you have not practiced with an administratively suspended license (form attached), 4. Arizona Statement of Citizenship and Alien Status for Public Benefits form, if you have not previously submitted the form with proof of status (form attached), 5. Audit form and documentation of continuing competence hours (form attached). Renewal and Reinstatement Fee: The fee may be paid in the form of a cashiers/personal/business check or money order.

Renewal Information: Arizona law requires that you notify the Board within 30 days of any change in your business address, home address, and telephone numbers. Renewal or reinstatement application with current information will suffice as a change of address. Licensees who change their names must provide the Board with correct and complete name change form and a copy of the legal document describing the change (e.g. copy of marriage license, divorce decree, driver's license etc.). To verify that your reinstatement has been processed, do a PT/PTA Search at the Board's website http://www.ptboard.az.gov, if your license status reads active, your reinstatement has been processed and you may practice in Arizona.

RETURN ALL REQUIRED FORMS WITH REINSTATEMENT & RENEWAL FEE Amount due for Reinstatement of administratively suspended license: $100.00 Amount due for Renewal period (9/01/10 to 8/31/12): $160.00 TOTAL DUE: $260.00 Amount Enclosed (cashier's/personal/business check or money order): $_____ ALL OF THE FOLLOWING FIELDS SHOWN BELOW ARE REQUIRED INFORMATION

An incomplete form will be returned for completion.

Name:

HOME INFORMATION

License #: ___________________

_______________________________________________________________________________________________ Street (including apartment / unit number if applicable) _______________________________________________________________________________________________ City State Zip _______________________________________ Home Telephone Number _______________________________________ Cell Phone Number

_________________________________________________________________________________ E-Mail Address

BUSINESS INFORMATION

Are you currently employed? (circle one) yes no

_______________________________________________________________________________________________ Business Name _______________________________________________________________________________________________ Street (including suite number if applicable) _______________________________________________________________________________________________ City State Zip _______________________________________ Business Telephone Number

PERSONAL INFORMATION: Please answer each of the following questions by checking the appropriate box on the right. All "Yes" answers MUST be explained in detail in a separate signed document. The document should include all relevant dates and identify the relevant jurisdiction and/or entity involved. Failure to attach all of the requested information (e.g. court dockets, arrest record, medical records) may result in the delay and/or denial of your reinstatement and renewal application. The questions pertain to the period from September 1, 2008 to the filing of this application. 1. 2. Have you been convicted of, pled guilty or no contest to, or entered into diversion in lieu of prosecution for any criminal offense in any jurisdiction of the United States or foreign country? Have you had an application for a professional or occupational license, certificate, or registration, other than a driver's license, denied, rejected, suspended, or revoked by any jurisdiction of the United States or foreign country? Are you currently or have you ever been under investigation, suspension, or restriction by a professional licensing board in any jurisdiction of the United States or foreign country for any act that occurred in that jurisdiction that would be the subject of discipline under this Chapter? Have you been the subject of disciplinary action by a professional association or post-secondary educational institution? Have you had a malpractice judgment against you or do you have a lawsuit currently pending for malpractice? Are you currently more than 30 days in arrears for payment required by a judgment and order for child support in Arizona or any other jurisdiction? Have you failed to adhere to the recognized standards of ethics of the physical therapy profession? Have you committed any of the actions referenced in the definition of good moral character in R4-24101? Good moral character means the applicant has not taken any action that is grounds for disciplinary action under A.R.S.§32-2044. Have you been the subject of any criminal investigation by a federal, state, or local agency or had criminal charges filed against you? YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO

3.

4. 5. 6. 7. 8.

9.

10. Do you have any impairment to your cognitive, communicative, or physical ability to engage in the practice of physical therapy with skill and safety? 11. Have you used alcohol, any illegal chemical substance, or prescription medicine that in any way has impaired or limited your ability to practice physical therapy with skill and safety? 12. Have you been diagnosed as having or are you being treated for bipolar disorder, schizophrenia, paranoia, or other psychotic disorder that in any way has impaired or limited your ability to practice physical therapy with skill and safety? 13. Have you ever violated A.R.S. § 32-2044(10) "Engaging in sexual misconduct."?

I affirm that I have complied with the medical records protocol as required in A.R.S. §32-3211. See Board website for further information. Signature: __________________________________________________ Continuing Competence (check one) I affirm that I have completed the required contact hours of continuing competence in accordance with A.A.C. Title 4, Chapter 24, Article 4. I have enclosed documentation of my required hours of continuing competence activities pursuant to R4-24-401(G). I affirm that I have completed the required contact hours of continuing competence after the 2008-2010 compliance period. I have enclosed documentation of my required hours of continuing competence activities pursuant to R4-24401(G). Signature: __________________________________________________ Date: __________________________ Date: __________________________

Under penalty of perjury, I declare and affirm that the statements made in this license renewal application are complete and correct and that any false or misleading information may be cause for denial or disciplinary action. To the best of my knowledge and belief I am not in violation of the provisions of the Arizona Physical Therapy Law. Signature: __________________________________________________ Date: __________________________

ARIZONA STATE BOARD OF PHYSICAL THERAPY 4205 N. 7th Ave, Ste 208 PHOENIX, ARIZONA 85013 Telephone (602) 274-0236 web: www.ptboard.az.gov

REINSTATEMENT OF AN ADMINISTRATIVELY SUSPENDED LICENSE AND LICENSE RENEWAL AFFIRMATION OF EMPLOYMENT STATUS FOR PERSONS WHO HAVE PRACTICED WITH AN ADMINISTRATIVELY SUSPENDED LICENSE NAME: _______________________________________________________________ DATE: __________________ License Number:___________ _____________________________ I have reviewed the statutory definition of "practice of physical therapy" at A.R.S. § 32-2001(11). I affirm that I have continued to practice as a physical therapist since my was administratively suspended on August 31, 2010. The following must be completed. If you require more space, attach a separate sheet that includes all the information requested below.

Name of facility, clinic, etc Address / City / State / Zip Phone w/ Area Code Dates of Employment

I am aware that until my license has been reinstated and renewed I may not legally practice as a physical therapist in Arizona. I am aware that practicing as a physical therapist with an administratively suspended license is in violation of A.R.S. § 32-2048 and may be grounds for disciplinary action pursuant to A.R.S.§ 32-2044. The Board has the investigative authority to validate your employment status. Signed: _____________________________________________________ Date:______________________________ If you prefer to consult with legal counsel prior to signing this affirmation, or to write your own affirmation, please be aware that you may not practice until your reinstatement and renewal application is complete (including an affirmation of employment status), your fees have been paid and your reinstatement has been processed.

ARIZONA STATE BOARD OF PHYSICAL THERAPY 4205 N. 7th Ave, Ste 208 PHOENIX, ARIZONA 85013 Telephone (602) 274-0236 web: www.ptboard.az.gov

REINSTATEMENT OF AN ADMINISTRATIVELY SUSPENDED LICENSE AND LICENSE RENEWAL AFFIRMATION OF EMPLOYMENT STATUS FOR PERSONS WHO HAVE

NOT PRACTICED WITH AN ADMINISTRATIVELY SUSPENDED LICENSE

NAME: ______________________________________________ DATE: __________________

License Number: _____________________________

Section 1: Check all that apply:

I affirm that currently I am not practicing in the State of Arizona I affirm that currently I am not residing in the State of Arizona

Section 2:

I have reviewed the statutory definition of "practice of physical therapy" at A.R.S. § 32-2001(11). I affirm that I am employed in Arizona but have not practiced as a physical therapist since my license was administratively suspended on August 31, 2010. Name of place of employment: ________________________________________________________ Address: __________________________________________________________________________

Street City State Zip Code

Telephone # (_______)_______________________________________

I am aware that until my license has been reinstated and renewed I may not legally practice as a physical therapist in Arizona. I am aware that practicing as a physical therapist with an administratively suspended license is in violation of A.R.S. § 32-2048 and may be grounds for disciplinary action pursuant to A.R.S. § 32-2044. The Board has the investigative authority to validate your employment status. Signed: __________________________________________________ Date: ____________________

If you prefer to consult with legal counsel prior to signing this affirmation, or to write your own affirmation, please be aware that you may not practice or work until your reinstatement and renewal application is complete (including an affirmation of employment status), your fees have been paid, and your reinstatement processed.

A.R.S. §32-2001, Definitions

11. "Practice of physical therapy" means: (a) Examining, evaluating and testing persons who have mechanical, physiological and developmental impairments, functional limitations and disabilities or other health and movement related conditions in order to determine a diagnosis, a prognosis and a plan of therapeutic intervention and to assess the ongoing effects of intervention. (b) Alleviating impairments and functional limitations by managing, designing, implementing and modifying therapeutic interventions including: (i) Therapeutic exercise. (ii) Functional training in self-care and in home, community or work reintegration. (iii) Manual therapy techniques. (iv) Therapeutic massage. (v) Assistive and adaptive orthotic, prosthetic, protective and supportive devices and equipment. (vi) Pulmonary hygiene. (vii) Debridement and wound care. (viii) Physical agents or modalities. (ix) Mechanical and electrotherapeutic modalities. (x) Patient related instruction. (c) Reducing the risk of injury, impairments, functional limitations and disability by means that include promoting and maintaining a person's fitness, health and quality of life. (d) Engaging in administration, consultation, education, and research.

ARIZONA STATEMENT OF CITIZENSHIP AND ALIEN STATUS FOR STATE PUBLIC BENEFITS

Professional License and Commercial License

Arizona State Board of Physical Therapy

Form 1: LONG FORM APPLICANT STATEMENT (revised) REQUIRING SUBMISSION OF DOCUMENTATION OF STATUS

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a professional license and commercial license issued by a State agency is a State public benefit. Arizona Revised Statutes § 1-501 requires, in general, that a person applying for a license must submit documentation to the licensing agency that satisfactorily demonstrates that the applicant is lawfully present in the United States. Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals must also complete Section III. Submit this completed form and copy of one or more documents that evidence your citizenship or alien status with your application for license or renewal.

SECTION I ­APPLICANT INFORMATION

APPLICANT'S NAME (Print or type) ____________________________________________________ DATE ____________ Note: If the document you are submitting to prove citizenship has a different name than what the Board has on record, please include the document that resulted in the name change ­ ie marriage license, divorce decree. TYPE OF APPLICATION. (check one):

_____ INITIAL APPLICATION

_______ RENEWAL

TYPE OF LICENSE (check one): _______PT _______PTA

LICENSE/CERTIFICATE #___________________

SECTION II ­ CITIZENSHIP OR NATIONAL STATUS DECLARATION

Directions: Attach a legible copy of the front and the back (if any) of a document from the attached List A or other document that demonstrates U.S. citizenship or nationality. Name of document provided: _____________________________________________________

A. Are you a citizen or national of the United States? (check one)

Yes No

B. If the answer is "Yes," where were you born? List city, state (or equivalent), and country City _____________________ State (or equivalent) __________________ Country or Territory _________________ If you are a citizen or national of the United States, go to Section IV. If you are not a citizen or national of the United States, please complete Sections III and IV.

SECTION III ­ ALIEN STATUS DECLARATION

Directions: To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the appropriate box. Attach a legible copy of the front and the back (if any) of a document from the attached List B or other document that evidences your status. A.R.S. § 1-501. Name of document provided: _______________________________________________________

"Qualified Alien" Status [8 U.S.C. §§ 1621(a)(1), -1641(b) and (c)]

1. 2.

An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA). An alien who is granted asylum under Section 208 of the INA.

Page 1 of 3

3. 4. 5. 6. 7. 8.

A refugee admitted to the United States under Section 207 of the INA. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. An alien whose deportation is being withheld under Section 243(h) of the INA. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980). An alien who is, or whose child or child's parent is, been declared a "battered alien" or an alien subjected to extreme cruelty in the United States.

Non-immigrant Status (8 U.S.C. § 1621(a)(2))

9.

A nonimmigrant under the Immigration and Nationality Act [§ U.S.C. S 1101 et seq.] Nonimmigrants are persons who have temporary status for a specific purpose. See 8 U.S.C. § 1101(a)(15).

Alien Paroled into the United States For Less Than One Year [8 U.S.C. § 1621(a)(3)]

10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA.

Other Persons (8 U.S.C. § 1621(c)(2)(A) and (C)

11. 12.

A nonimmigrant whose visa for entry is related to employment in the United States, or

A citizen of a freely associated state, if section 141 of the applicable compact of free association approved in Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States include the Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 et seq.];

13.

A foreign national not physically present in the United States.

Otherwise Lawfully Present (A.R.S. § 1-501)

14.

A person not described in categories 1-13 who is otherwise lawfully present in the United States. PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons who fall into this category ineligible for licensure. See 8 U.S.C. § 1621(a).

SECTION IV - DECLARATION All applicants must complete this section. I declare under penalty of perjury under the laws of the state of Arizona that the answers I have given are true and correct to the best of my knowledge

________________________________________________ APPLICANT'S SIGNATURE

_________________________________ TODAY'S DATE

Attachment: Lists A and B Evidence of U.S. Citizenship, U.S. National Status, or Alien Status

11/8/07 81662

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41-1080. Licensing eligibility; authorized presence; documentation; applicability; definitions

A. After September 30, 2008 and subject to subsections C and D, an agency or political subdivision of this state shall not issue a license to an individual if the individual does not provide documentation of citizenship or alien status by presenting any of the following documents to the agency or political subdivision indicating that the individual's presence in the United States is authorized under federal law: 1. An Arizona driver license issued after 1996 or an Arizona nonoperating identification license. 2. A driver license issued by a state that verifies lawful presence in the United States. 3. A birth certificate or delayed birth certificate issued in any state, territory or possession of the United States. 4. A United States certificate of birth abroad. 5. A United States passport. 6. A foreign passport with a United States visa. 7. An I-94 form with a photograph. 8. A United States citizenship and immigration services employment authorization document or refugee travel document. 9. A United States certificate of naturalization. 10. A United States certificate of citizenship. 11. A tribal certificate of Indian blood. 12. A tribal or bureau of Indian affairs affidavit of birth. This section does not apply to an individual, if all of the following apply: 1. The individual is a citizen of a foreign country or, if at the time of application, the individual resides in a foreign country. 2. The benefits that are related to the license do not require the individual to be present in the United States in order to receive those benefits. If, pursuant to subsection A, an individual has affirmatively established citizenship of the United States or a form of nonexpiring work authorization issued by the federal government, the individual, on renewal or reinstatement of a license, is not required to provide subsequent documentation of that status. If, on renewal or reinstatement of a license, an individual holds a limited form of work authorization issued by the federal government that has expired, the individual shall provide documentation of that status. For the purposes of this section: 1. "Agency" means any agency, department, board or commission of this state or any political subdivision of this state that issues a license for the purposes of operating a business in this state. 2. "License" means any agency permit, certificate, approval, registration, charter or similar form of authorization that is required by law and that is issued by any agency for the purposes of operating a business in this state. Page 3 of 3

B.

C.

D.

E.

For Staff Use Only In Compliance

Arizona State Board of Physical Therapy Continuing Competence Audit Reporting Form Compliance Period: 9/01/08­8/31/10

License # ______________ Date _____________

Licensee Name: ________________________________

To qualify as a Category A activity a course must be approved for contact hours by a PT, medical or health care 1) accredited program, 2) state or national association or component of the association or 3) national specialty society. Regardless of the sponsoring organization, approval by a Category A organization will qualify a course as Category A, whether the course is taught in a classroom, on the internet or through home study. Category A activities include continuing education coursework, coursework towards granting or renewal of PT clinical specialty certification, coursework in a PT clinical residency program and coursework in post-graduate PT education from an accredited college or university, including transitional DPT programs.

CATEGORY A (MIN. 10 HRS)

Title of course, seminar, etc. Date(s) of course Contact Hours CEUs Approved By (Category A organization) Documents Attached

FOR AUDITOR USE ONLY

Hours Hours not approved approved Reason for disapproval

TOTALS

MAKE SURE YOUR DOCUMENTATION INCLUDES DATE, PLACE, COURSE TITLE, COURSE SPONSOR, SCHEDULE, PRESENTER, NUMBER OF CONTACT HOURS RECEIVED FOR THE ACTIVITY AND PROOF OF COMPLETION.

1

INITIAL AUDIT REPORTING FORM

Licensee Name: ________________________________ CATEGORY B

Title of course, seminar, etc. B1 Study Group­5 hours maximum

License # ______________

Date _____________

Description of category activities below.

Date(s) Contact Hours CEUs Approved By Documents Attached

FOR AUDITOR USE ONLY

Hours Hours not approved approved Reason for disapproval

Structured meeting for study of clinical PT topic dealing with current research, clinical skills, procedures or treatment related to practice of PT. Minimum of 3 participants; each 2 hours participation=1 contact hour.

B2 Self-Instruction­5 hours maximum treatment related to practice of PT. 60 minutes of self-instruction=1 contact hour.

Structured course of study relating to one clinical physical therapy topic dealing with current research, clinical skills, procedures, or

B3 In-Service­5 hours maximum

Attendance at a presentation pertaining to current research, clinical skills, procedures or treatment related to practice of PT OR relating to patient welfare of safety, including CPR certification. 60 minutes of inservice=1 contact hour.

TOTALS

MAKE SURE YOUR DOCUMENTATION INCLUDES DATE, PLACE, COURSE TITLE, COURSE SPONSOR, SCHEDULE, PRESENTER, NUMBER OF CONTACT HOURS RECEIVED FOR THE ACTIVITY AND PROOF OF COMPLETION

2

INITIAL AUDIT REPORTING FORM

Licensee Name: ________________________________ CATEGORY C

Title of course, seminar, etc. C1 Practice Management­5 hours max.

License # ______________

Date _____________

Description of category activities below.

Date(s) Contact Hours CEUs Approved By Documents Attached

FOR AUDITOR USE ONLY

Hours Hours not approved approved Reason for disapproval

Coursework concerning physical therapy administration, professional responsibility, ethics, or legal requirements applicable to PT practice settings. Must receive 'pass' in pass/fail or minimum grade of 'C' if graded. 60 minutes coursework=1 contact hour.

C2 Teaching/Lecture­5 hours maximum

Presentation of an original education program dealing with current research, clinical skills, procedures, treatment, or practice management related to the practice of PT principally for health care professionals. Must be accompanied by written materials prepared, augmented or updated by presenter. 60 minutes of instruction=2.5 contact hours.

C3 Publication­5 hours maximum

Writing for professional publication, platform or poster presentation abstracts applicable to practice of PT. Credit may be earned for material that is a minimum of 1500 words and published by recognized 3rd party publisher.

TOTALS

MAKE SURE YOUR DOCUMENTATION INCLUDES DATE, PLACE, COURSE TITLE, COURSE SPONSOR, SCHEDULE, PRESENTER, NUMBER OF CONTACT HOURS RECEIVED FOR THE ACTIVITY AND PROOF OF COMPLETION.

3

INITIAL AUDIT REPORTING FORM

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