Application For A License To Practice Podiatric Medicine Page 11
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If necessary, continue to list on a separate sheet of paper labeled with your name and signed by you.
22.
Medical Malpractice History
Have you ever had any claims of malpractice filed against you?
No
Yes
If Yes, please list all claims of malpractice filed against you below. Include all settlements, judgments, awards, and
claims, even if no money was paid. For each case listed below, provide an explanation and documentation.
Provide your explanation on a separate sheet of paper labeled with your name, and signed by you; include a brief
description regarding the nature of the case, the allegations, and your response to the allegations. Letters from
attorneys or insurance carriers may not be substituted for this required explanation. Documentation includes a
copy of the order for settlement, dismissal, or removal from the case, or other documentation to support your
explanation. Please do not send all of the motions or filings for the case.
Case
Date of
Jurisdiction
Amount of Settlement
No.
Case (Mo/Yr)
(State, etc.)
Nature of Allegation
Paid on Your Behalf
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Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 5 of 9
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