Application and Forms

If a “Yes” response was provided to any of the questions in this 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.

If you responded “Yes” to any of the questions in this section, you must provide the following:

A written self-explanation, describing in detail the circumstances surrounding the disciplinary action.

A copy of the administrative complaint and final order.

If you responded “Yes,” you must provide the following:

A written self-explanation, describing in detail the circumstances surrounding each offense; including date, city and state, charges and final results.

Final dispositions and arrest records for all offenses. The clerk of  court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the clerk of court.

Completion of Sentence Documents. You may obtain documents from the Florida Department of Corrections. The report must include the start date, end date, and that the conditions were met.

Effective July 1, 2012, section 456.0635, Florida Statutes, 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or applicant has successfully completed a drug court program for that felony and provides proof that the plea has been withdrawn or the charges have been dismissed.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. 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. Felonies of the third degree, more than 10 years from the date of the plea, sentence and completion of any subsequent probation.
   3. 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. 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. 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. 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. Currently listed on the United States Department of Health and Human Services Office of Inspector General’s list of excluded individuals and entities.