North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 52 - PODIATRY EXAMINERS › Section .0200 - EXAMINATION AND LICENSING › Section 52 .0207 - ANNUAL RENEWAL OF LICENSE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
				executive secretary of the board shall mail to the last known address of each
				license holder each year a form on which to apply for renewal of his or her
				license. The renewal application shall be pre-populated with information
				contained in the board's licensee database with a space for corrections or
				additions with regard to the following information about the licensee:
(1) Social security number;
(2) National Provider Number (NPI), if
				any;
(3) Drug Enforcement
				Administration License Number (DEA), if any;
(4) Marital status;
(5) Name;
(6) NC license number;
(7) Birthdate;
(8) Other states licensed in and license
				numbers;
(9) Home address and phone
				number;
(10) Business address and
				phone number;
(11) Preferred
				mailing address (business or home);
(12) Email address:
(13) Whether or not the licensee would like
				to receive email correspondence from the board;
(14) Medicare provider number;
(15) Present practice status (e.g., active,
				teaching, retired, residency, other);
(16) Principal setting of practice (e.g.,
				hospital, nursing home, free-standing clinic, group, practitioner's office,
				nonfederal health facility, military facility, Veteran's Administration medical
				facility, school, other);
(17) Form
				of employment (e.g., self-employed as a solo practitioner or non-solo
				practitioner, or employee of individual practitioner, partnership or group,
				government, other);
(18) National
				board certifications (American Board of Podiatric Surgery, American Board of
				Foot and Ankle Surgery, American Board of Lower Extremity Surgery, and American
				Board of Multiple Specialties in Podiatry);
(19) Hospital staff privileges (hospital,
				location, date privileges began, type of privileges), any denial of such
				privileges, and the reason for such denial since last renewal
				application;
(20) Whether or not
				the licensee performs amputations, ankle surgery, or clubfoot
				procedures;
(21) Whether or not the
				licensee is granted specialty privileges by the board for amputations, ankle
				surgery, or clubfoot procedures;
(22) Continuing Medical Education (CME)
				credits earned in the previous license year, pursuant to
				G.S.
				90-202.11 and S.L. 2015-241, s. 12F,
				16(c);
(23) Whether or not the
				licensee has ever had a license revoked, suspended, denied, or cancelled; been
				a defendant in a legal action involving professional liability (malpractice),
				been named in a malpractice suit, had a professional liability claim paid on
				the applicant's behalf or paid such a claim; been a patient for the treatment
				of mental illness; been addicted to drugs or alcohol; or been convicted of a
				felony; and any explanation regarding such information that the applicant
				wishes to present to the board;
(24) Original signature;
(25) Date of renewal application;
				or
(26) Desire not to renew
				license.