Request Form For Duplicate/revised Reports Of A Physical Therapy Evaluation Form California
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1For Office Use Only
INTERNATIONAL EDUCATION
Ref. #: ____________________
RESEARCH FOUNDATION, INC.
Date:
____________________
Fees: _____________________
REQUEST FORM FOR DUPLICATE/REVISED REPORTS OF A PHYSICAL THERAPY EVALUATION
2011
Please note that there is a five-year limit on requests for copies of any evaluation. We are currently able to issue duplicate copies of reports dated 2010 and
2011
thereafter. For evaluations issued prior to 2010, a new report and new application fees are required. IERF reserves the right to deny a request for a duplicate
copy on the basis of changes that may have taken place in: 1) the educational system of the country of study, 2) IERF policy, or 3) the requirements of the
institution/licensing board/agency to which the report is to be sent, since the time the initial report was issued. In such a case, a new report and new application
fees are required. A separate form is required for services other than duplications/revisions of Physical Therapy Evaluations.
Please complete this form clearly and return it with your payment.
Section 1: Applicant Information
Name: ____________________________________________________________________________________________________
Family/Last
Given/First
Second/Middle
Mailing Address: ____________________________________________________________________________________________
Number
Street
Apt. #
____________________________________________________________________________________________
City
State
Zip/Postal Code
Country
Telephone: (
) ________________ (
) _______________ Fax: (
) _____________ Cell: (
) ____________________
Day
Evening
IERF File #
Email: ___________________________________________
______________________________________ (Please provide.)
Section 2: Fees
Section 3: Services and Fees
REPORTS
REPORTS
One official copy and one applicant copy are included in the fee. As
1. Duplicate Report (Same State/Type of Licensure Only)
Licensure: PT PTA ($125)
required by the state boards, copies of all files are forwarded for
State: _____
$ _______
consultation to a licensed practicing physical therapist, who is
employed by IERF. Existing evaluation reports will be modified to
2. Revised Report (for new states, new types of licensure (PT or
reflect current individual state regulations.
PTA), and/or for additional studies)
1. Duplicate Report (Same State/Type of Licensure Only) – $125
First Report:
(with no additional studies or modifications). Allow 15 business
State: _____
Licensure:
PT
PTA ($325)
$ _______
days from the receipt of all required documentation (and/or fees)
for your report to be mailed.
Additional Report:
State: _____
Licensure:
PT
PTA ($150)
$ _______
2. Revised Report – $325 for the first report and $150 for each
additional state or type of licensure (PT or PTA) requested at the
Additional Report:
new states, new types of
same time. Revisions include reports for
State: _____
Licensure:
PT
PTA ($150)
$ _______
licensure (PT or PTA), and/or for additional studies
. Allow 60
business days from the receipt of all required documentation
(and/or fees) for your report to be mailed.
MAILING OPTIONS (prices are per address)
State Boards of Physical Therapy
Please refer to our website for the list of state boards that accept
Domestic
IERF evaluations.
Secure Mailing (add $20 each)
$_______
applicant
state board(s) in: ______________________________
Next Day Delivery (add $35 each)
$ _______
Section 4: Certification
applicant
state board(s) in: ______________________________
I agree to be bound to the same terms and conditions as
those in my initial application.
International Secure Mailing (add $75)
$_______
applicant
0
Signature
Date
TOTAL $ _______
International Education Research Foundation, Inc., P.O. Box 3665, Culver City, California 90231-3665
Rev 12/15
Rev. 07/15
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