Certified Pedorthist Membership Eligibility Verification

Date of Application*

Current Employment*

I am currently Unemployed
I currently work in the pedorthic or similar industry
My current employment is not in the pedorthic or similar field

Name*

First Last

Email*

Enter Email Confirm Email

Cell Phone*

Home Phone*

Home Address*

Street Address Address Line 2 City Province Postal Code

Company Name*

Position in the Company*

Name of Company Owner*

Company Address*

Street Address Address Line 2 City Province Postal Code

Company Phone*

Company Website

Year Business Started*

Are you currently or have you ever worked as a health professional in any other discipline?*

No
Yes

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

Pedorthic Credential*

Year Pedorthic Credential was obtained*

Pedorthic Credential Number*

Do you hold a minimum of $1,000,000 in professional liability insurance?*

Yes
No

Has your pedorthic certification ever been suspended or revoked?*

Yes
No

If yes, please explain in detail.*

Have you ever been denied as a provider by an extended health benefits provider?*

Yes
No

If yes, please explain in detail.*

Has an extended health benefits provider ever made a formal or informal complaint against you, a business partner of yours, or a company you have been employed by?*

Yes
No

If yes, please explain in detail.*

Name of the Clinic where you completed your pedorthic internship.*

What is the name and credential of the individual who signed your pedorthic clinical attestation (clinical hours)?*

Education and work experience verification.*

PFA Canada has already assessed and verified that my pre-requisites have been met.
PFA Canada has not already assessed and verified that my pre-requisites have been met.

EDUCATION - Indicate the number of educational programs you will be submitting with your application. Be sure to include all course work you have taken after high school. This section does not include work experience. If the program or courses your are submitting have been taken outside of Canada or the United States you will be required to have your program verified through the World Education Service.*

Education 1 - In the space below enter your 1st educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 1st educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 2 - In the space below enter your 2nd educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 2nd educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 3 - In the space below enter your 3rd educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 3rd educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 4 - In the space below enter your 4th educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 4th educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 5 - In the space below enter your 5th educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 5th educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 6 - In the space below enter your 6th educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 6th educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

Education 7 - In the space below enter your 7th educational experience. Be sure to include the name and address of the institution, program/courses taken, dates attended and please indicate if it was a in class or online program*

Scan and attach course info pertaining to your 7th educational experience indicated above - including degree, diploma, certificates, transcripts, etc*

Max. file size: 128 MB.

WORK EXPERIENCE - Indicate the total number of previous employment positions you will be submitting with this application.*

Employment Experience 1 - In the space below enter the first job you wish to submit. Be sure to include the name and address of the company, your position, dates you worked there, duties performed and the name, phone number and email address of your supervisor. (only enter one job per section)*

Employment Experience 2 - In the space below enter the second job you wish to submit. Be sure to include the name and address of the company, your position, dates you worked there, duties performed and the name, phone number and email address of your supervisor. (only enter one job per section)*

Employment Experience 3 - In the space below enter the third job you wish to submit. Be sure to include the name and address of the company, your position, dates you worked there, duties performed and the name, phone number and email address of your supervisor. (only enter one job per section)*

Employment Experience 4 - In the space below enter the fourth job you wish to submit. Be sure to include the name and address of the company, your position, dates you worked there, duties performed and the name, phone number and email address of your supervisor. (only enter one job per section)*

Employment Experience 5 - In the space below enter the fifth job you wish to submit. Be sure to include the name and address of the company, your position, dates you worked there, duties performed and the name, phone number and email address of your supervisor. (only enter one job per section)*

REFERENCE LETTERS - Attach 3 letters of reference below (references may include employers, mentors, physicians, etc) - All reference letters must be dated and signed*

Drop files here or

Max. file size: 128 MB.

Declaration - I authorize PFA Canada to make any inquiries it deems necessary to authenticate my qualifications. I understand that all information provided will be treated with confidentially except when required by law. I have read and understand the application process. I declare that the information I have provided to be true and that my Proof of Eligibility is genuine. I understand that false application information or evidence of tampering with the membership procedures may result in my disqualification from PFA Canada.*

I agree

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 below and agree to abide by this code.

Application Fee (non-refundable)

Subtotal

$ 0.00 CAD

Tax

$ 0.00 CAD

HST # 818607632RT0001

Total

$ 0.00 CAD

Credit Card*

American Express

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Phone

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Certified Pedorthist – PFA Canada Membership Eligibility Verification