Certified Pedorthist Application

Date of Application*

Name*

First Last

Email*

Enter Email Confirm Email

Cell Phone*

Home Phone*

Home Address*

Street Address Address Line 2 City Province Postal Code

Profile Picture - Submit a color photo of yourself without sunglasses or a hat for your online listing. This listing will be viewed by insurance companies wanting to confirm your membership in PFA Canada.*

Max. file size: 128 MB.

Company Name*

Position in the Company*

Name of Company Owner*

Company Address*

Street Address Address Line 2 City Province Postal Code

Company Phone*

Website*

This company has a website
There is no website for this company

Please explain why this company does not have a website.

Company Website*

Year Business Started*

Company Photo - Submit a color photo of the outside of the company.*

Max. file size: 128 MB.

Do you belong or have you ever belonged to any other health association?*

No
Yes

If yes, indicate which profession(s) and include any professional associations to which you belong.

If yes, have you ever been disciplined by a health association, or disqualified as a provider from any insurance company?*

Yes
No

Please explain the situation which led to the disciplinary action.*

Pedorthic Credential*

Certification - Submit a copy of your credential certificate or confirmation of your certification.*

Max. file size: 128 MB.

Year Pedorthic Credential was obtained*

Pedorthic Credential Number*

Maintain Pedorthic Credential*

I understand that my pedorthic credential must be maintained as a condition of PFA Canada membership.

Professional Liability Insurance*

I am aware that am required to always provide a current copy of my professional liability coverage to PFA Canada.

Membership Eligibility*

I have written and passed the PFA Canada exam.

PROFESSIONAL LIABILITY INSURANCE - Attach proof of your professional liability insurance. Please note the policy must state your name on the policy, not just the business name.*

Max. file size: 128 MB.

I agree that PFA Canada may investigate on any of the above and should it be found that any false information has been provided, my membership to PFA Canada may be automatically revoked without warning or explanation and no refund of membership shall be due. Should PFA Canada require legal advice in regards to a member's application, the member will be notified and the member may be responsible for the costs incurred by the investigation. Please note that membership with PFA Canada is a privilege. Our mandate is not only to represent our certified pedorthist members, but also to protect the public and ensure best business practices. PFA Canada membership is at the discretion of the BOD and its membership/Discipline committee and a certified pedorthist membership may be denied/revoked if it is deemed by the BOD to have a negative effect on the public or the reputation of PFA Canada as a whole.*

I agree have read the information above carefully.

Code of Conduct - The pedorthic profession exists for the primary purpose of assisting patients with maintaining functional lives. Certified Pedorthists assume specific responsibilities to physicians and other appropriately licensed healthcare prescribers, patients, the public, colleagues as well as to the profession itself. Members of the profession are responsible for maintaining and promoting ethical practice including, without limitation, reporting unethical practices. This code shall be binding upon all Certified Pedorthists who maintain membership with this association. Certified Pedorthists are obligated to report knowledge of code violations within 30 days. Certified Pedorthists who fail to conform to this code will be subject to disciplinary action. All certified members of PFA Footcare Association (Canadian Chapter) shall: 1. Receive a prescription from a medical doctor, podiatrist or chiropodist before providing any custom made pedorthic devices to a patient. 2. All decisions by a certified pedorthist must be made with the understanding that the patient’s best interests are the primary concern. 3. Members must not suggest, or imply patients receive products where misuse and abuse of a patients insurance benefit policy is evident. (For example: not all patients require compression stockings) 4. A patient’s personal information shall remain confidential and may not be communicated to any person or entity other than with the referring professional. All other communications related to the exchange of personal information must have prior written consent from the patient. 5. Provide receipts clearly indicating products and services received. Providing a receipt for orthotics and orthopedic footwear as one single item is prohibited. 6. Members are not permitted to offer free shoes/merchandise, or offer a discounted rate on these products as a benefit for patients purchasing custom made orthotics or compression stockings. 7. Use sound judgment in regard to safety of self and others, and adhere to safety procedures throughout the delivery of pedorthic services. 8. Not receive, transfer or assign funds with regards to the referral of a patient. 9. A certified pedorthist shall not delegate a task requiring a unique skill, knowledge or judgement to an unqualified person. 10. Advertising must not contain false, fraudulent, misleading, deceptive or unfair claims. 11. Provide ethical, patient-centered care by operating within your certification requirements and Code of Professional Responsibilities. 12. Practice with awareness of humanity/dignity and not decline a patient based on race, color, gender, sexual preference, religion or national origin. 13. Not have consensual or non-consensual sexual relations with current or former patients. These relations are prohibited unless: the relationship existed prior to the provision of service, the patient has not received service from the provider for one year, service has not been provided within one year after the termination of the sexual relationship. 14. Conduct themselves in a manner that will assure the dignity of the profession. Unacceptable behavior includes, but not limited to, misusing of credentials, slander, falsifying documents, or misrepresenting ones capacity as a service provider. 15. Not use illegal drugs and/or any legally controlled substances resulting in the impairment of his/her professional judgement and/or ability to provide service. 16. Not solicit the patronage of patients by way of intimidation, threats, harassing conduct, duress, coercion, remuneration or unwarranted promises of benefits. 17. Maintain the security and prevent the disclosure of credentialing exams and their content. 18. Adhere to the rules, regulations, standards of practice and code of conduct as required for the Certified Pedorthist to maintain their credential. 19. Have $1,000,000 of Professional Liability / Errors and Omissions insurance coverage.*

I have read the code of conduct and agree to abide by this code.

Certified Pedorthist Membership Fee (Pro-rated) - Please select the month this application is being submitted to ensure your membership rate is pro-rated.*

Subtotal

$ 0.00 CAD

Total

$ 0.00 CAD

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.

Certified Pedorthist – Membership Application