SUPERVISING
CHIROPRACTOR APPLICATION
(Requirements revised &
promulgated in COMAR 10.43.07, Oct. 22, 2007)
The Board certifies active licensed chiropractors as
‘Supervising Chiropractors.’ This is an important responsibility for a
licensee since a Supervising Chiropractor is authorized to supervise, train and
mentor Chiropractic Assistants and Trainees. The Board takes this certification
process very seriously. On
October 22, 2007, revised regulations were promulgated that
significantly increased the requirements and oversight of Supervising
Chiropractors and applicants.
To qualify for certification as a Supervising Chiropractor,
applicants must meet the following requirements:
-
Hold an active license in
good standing with physical therapy privileges
-
Possess high moral and
professional standards. A history of practice misconduct or criminal
misconduct or censure or sanctions from an administrative board in Maryland
and/or in another jurisdiction may result in disapproval of the application
-
Legibly complete and sign
this application
-
Pay the non-refundable
application fee of $300.00
-
Take and successfully pass a
Supervising Chiropractor Examination
-
Successfully pass a personal
screening by the Board (at its discretion)
-
Submit verified documentation
if requested regarding educational, professional or disciplinary matters
- Submit
a formal, typed petition (single spaced, not more than 300 words) on
letterhead stating your qualifications, especially your qualifications for
supervision and why the Board should issue you a Supervising Chiropractor
Certification.
Legibly (print or type) Answer
the Following
APPLICANT
NAME__________________________________________________________
MAILING
ADDRESS_________________________________________________________
LICENSE
NO.____________PHONE_____________________ E-MAIL_______________
CHIRO.
COLLEGE ATTENDED/GRADUATED_____________________________________
YEAR OF
CHIRO COLLEGE GRADUATION________ GPA_______ HONORS_________
NAME OF
PRACTICE WHERE WORKING (IF SOLO, WRITE SOLO)
__________________________________________________________________________
NUMBER OF
CHIROPRACTOR AT THE PRACTICE______ NUMBER OF C.A.s_________
NUMBER OF
MASSAGE THERAPISTS______
1 of
2 SEE REVERSE
LIST ALL
TYPES OF PHYSICAL THERAPY MODALITIES UTILIZED IN YOUR PRACTICE
Ultrasound___ Electro Stimulation___ Ultraviolet___
T.E.N.S.____
Faradic
____ Low Volt Galvanic____ Hydrocollator Packs ____
Inferential ____ Sinusoidal____ Parafin____
Infared:
Shortwave____ Longwave____ Diathermy: Shortwave____ Longwave____
Hydrotherapy: Whirlpool____ Contrast____ Sitz____
Hubbard____
Cryotherapy: Cold packs____ Ice Bags____ Ice
rub____
Compression____ Vapocoolant____
Traction: Cervical____ Intersegmental____
Lumbar____
List here
any clarifications or additional modalities not cited above:
_____________________________________________________________________________
The undersigned agrees to fully comply with each and every
law and regulation enacted and promulgated regarding the practice of
chiropractic and chiropractic assistants pursuant to the regulations as revised
on October 22, 2007 as set forth in COMAR 10.43.07 et seq. and the other
general provisions of the chiropractic and C.A. regulations. I have read and
understand the provisions of law and regulation as cited above. I agree to the
release of any/all information from any source, including educational,
disciplinary, administrative or professional that the Board may require in
reviewing this application.
_________________________________
_______________________
_______
Applicant
Name Signature
Date
UPON RECEIPT OF THE APPLICATION FEE AND ALL REQUIRED ITEMS,
YOUR APPLICATION WILL BE REFERRED FOR REVIEW TO THE BOARD INVESTIGATOR AND TO
THE BOARD EDUCATIONAL SUBCOMMITTEE. UPON TENTATIVE APPROVAL, YOU WILL BE
NOTIFIED OF THE TIME/DATE/LOCATION OF THE SUPERVISING CHIROPRACTOR EXAMINATION.
IN THE INTERIM, YOU ARE STRONGLY ADVISED TO DOWNLOAD THE REVISED REGULATIONS
ONLINE AT THE BOARD WEBSITE AT
WWW.MDCHIRO.ORG. FOR THE EXAMINATION, YOU ARE RESPONSIBLE FOR COMAR
10.43.07.01 THROUGH 10.43.07.09. THE EXAMINATION IS MULTIPLE CHOICE AND
REQUIRES A PASSING SCORE OF 75%.
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Revised 10/07
