Council on Forensic Sciences

Membership Application Form

Name: College on Forensic Sciences - Membership
Office Address: College on Forensic Sciences - Membership
City: College on Forensic Sciences - Membership

State:

College on Forensic Sciences - Membership

Zip:

College on Forensic Sciences - Membership
Mailing Address: College on Forensic Sciences - Membership
  (if different from above)
City: College on Forensic Sciences - Membership

State:

College on Forensic Sciences - Membership

Zip:

College on Forensic Sciences - Membership
Email: College on Forensic Sciences - Membership
Phone: College on Forensic Sciences - Membership
Phone (Cell): College on Forensic Sciences - Membership

Personal Information

Social Security #: College on Forensic Sciences - Membership

Date of Birth:

College on Forensic Sciences - Membership
      (mm/dd/yyyy)
Professional College: College on Forensic Sciences - Membership
Degree(s)/Institution: College on Forensic Sciences - Membership

Date of Graduation:

College on Forensic Sciences - Membership
      (mm/dd/yyyy)
State(s) Licensure: College on Forensic Sciences - Membership College on Forensic Sciences - Membership College on Forensic Sciences - Membership
License Number(s): College on Forensic Sciences - Membership College on Forensic Sciences - Membership College on Forensic Sciences - Membership
Membership Recommended by: College on Forensic Sciences - Membership

Requested Documents to be forwarded:

  College on Forensic Sciences - MembershipCompleted Application and Consent & Release
  College on Forensic Sciences - MembershipCompleted Consent & Release
  College on Forensic Sciences - MembershipCompleted Attestation
  College on Forensic Sciences - MembershipCopies of State License(s)
  College on Forensic Sciences - MembershipDiplomate Certificate(s) and Specialty Training Certificates
  College on Forensic Sciences - MembershipACA membership verified by email or fax
  College on Forensic Sciences - MembershipMalpractice Insurance Declaration Page
  College on Forensic Sciences - MembershipExplanation/status of any Malpractice Cases
  College on Forensic Sciences - MembershipCopy of Professional Diploma
  College on Forensic Sciences - MembershipCurrent Curriculum Vitae

Consent & Release

By applying for membership, I agree to the following:

1. To immediately notify - in writing - the CFS of any changes made or proposed in the status of my professional license, to my practice and/or mailing address, or any other demographic information.
2. To hold harmless and release from any and all liability, the CFS, its authorized representative(s), and any third parties who, in good faith and without malice, review, act or provide information regarding my background, experience, clinical competence, professional ethics, utilization patterns, health status, and/or other qualifications for application approval.
3. To abide by the terms of the CFS bylaws, Guideline of Conduct, and Rules and Regulations, as amended and as related to the policies and procedures of the CFS and its members.
 
1. The forensic examiner shall perform duties in accordance with the applicable law(s) and shall observe the highest of ethical and moral principles, evidence-influenced standards/guidelines and policies of professional practice.
2. The forensic examiner shall at all times act with integrity, truthfulness and honesty.
3. The forensic examiner shall observe diligence in the discharge of professional responsibilities.
4. The forensic examiner shall exhibit competence at all times in the discharge of professional responsibilities.
5. The forensic examiner shall at no time divulge confidential information in an inappropriate or unlawful manner and shall exercise the care required for confidentiality and privacy consistent with the applicable legal jurisdiction.
6. The forensic examiner shall not maliciously injure the reputation or professional practice of providers, employers, insurers, claimants, or other parties.
7. The forensic examiner shall divulge and report appropriately when faced with potential conflicts of interest.
8. The forensic examiner shall try to remain unbiased and objective, so that trier of fact is served by accurate determination of the facts involved.
9. The forensic examiner shall thoroughly review and analyze the evidence in a case, conduct evaluations based on established scientific principles, methodology, facts and evidence-influenced knowledge and training, and render opinions which have a demonstrably reasonable basis and within the forensic examiner's qualifications and scope of practice.
10. The forensic examiner shall not intentionally withhold or omit any findings or opinions discovered during a forensic evaluation or review that would cause the facts of a case to be misinterpreted or distorted.
11. The forensic examiner shall never misrepresent credentials, education, training, experience, or membership status.
12. The forensic examiner shall refrain from any conduct that would be adverse to the best interest and purpose of the Council on Forensic Sciences and/or the American Chiropractic Association.
13. The forensic examiner shall respect the rights of the examinee and other participants, and treat these individuals with dignity and respect.
14. At the forensic medical examination, the forensic examiner shall:
 
A. Introduce themseif to the examinee as the examiner.
B. Advise the examinee they are presenting for an independent medical examination, and the information provided will be used in the assessment and presented in a report.
C. Confirm with the examinee with the name of the entity requesting the examination.
D. Advise the examinee that a limited doctor/patient relationship (diagnose, maintain confidentiality and divulge) will be established.
E. Confirm informed consent and explain the examination procedure(s).
F. Provide adequate draping and privacy if the examinee needs to remove clothing for the examination.
G. Allow a family member or friend to attend non psychiatric portions of the examination, if requested by the examinee and if the other person is not disruptive or interferes.
H. Refrain from derogatory comments.
I. Close the examination by telling the examinee that the examination is over and ask if there is further information that the examinee would like to add.
15. The forensic examiner shall be prepared to address conflict in a professional and constructive manner.
16. The forensic examiner shall never accept a fee for services which is dependent upon writing a report favorable to the referral service. The forensic examiner shall continue to study, apply, and advance scientific knowledge, maintain a commitment to continuing subspecialty education, obtain consultation, and use the talents of other healthcare professionals when indicated.
4. To authorize the CFS or its representative(s) to make inquiry, perform a background check, to consult with prior associates or others who may have information regarding my background, experience, clinical competence, professional ethics, utilization patterns, health status, and/or other qualifications that may be material to this membership.
5. To attest to the correctness and completeness of all information provided in this application, and to further acknowledge that any material, misstatement, or intentional omission of information from this application constitutes grounds for denial of membership and/or summary dismissal.

* By submitting this application or my signature below(if printed copy), I certify that I have read and understand the above-captioned CFS Guidelines of Conduct and agree to comply with same.

 
I Agree College on Forensic Sciences - Membership
 
I Disagree College on Forensic Sciences - Membership

PROFESSIONAL QUESTIONS AND ATTESTATIONS

 For each “ YES” response, please attach a detailed explanation to this form.

YES/ NO

Has your license to practice in any jurisdiction - whether completed or still pending - been denied, restricted, limited, suspended, revoked, not renewed; OR have you ever been placed under probation, subjected to disciplinary action, or otherwise sanctioned, limited, or curtailed; OR have you voluntarily relinquished any item in anticipation of any of these?

____ ____

Has your professional liability insurance ever been denied, suspended, canceled, or not renewed?

____ ____

 Has your status as a provider ever been denied, suspended, canceled, or sanctioned OR has any disciplinary action ever been taken against you, OR are you currently under investigation by any municipal, state, federal, or any other governmental agency as well as HMO, PPO, or other prepaid health plan (e.g. Medicare, Medicaid, Medi-Cal)?

____ ____

Are your privileges or memberships at any hospital, institution (Military service) and/or HMO currently under investigation or have they ever been denied, suspended, reduced, or not renewed; OR have any other disciplinary proceedings ever been instituted against you?

____ ____

Have you ever been denied membership, or renewal thereof, or been subject to disciplinary proceedings by any professional organization?

____ ____

Are you prevented from performing any procedures within the scope of privileges and duties as a healthcare provider?

____ ____

Do you currently, or did you in the last two years, engage in the unlawful use of drugs, including the improper use of prescription drugs?

____ ____

Do you have any felony or misdemeanor charges pending against you, other than a traffic violation; OR have you ever been convicted of a felony, or pleaded “nolo contendere” to a felony or negotiated a plea?

____ ____

Have you EVER been or are you currently involved in ANY malpractice (or other civil) claims/lawsuits, settlements, judgments? If ‘YES’, please provide detailed information on a separate sheet of paper including: Docket # of the case, location of the court, the names of the parties plaintiff(s) and defendant(s), description of the incident(s), date(s) of the incident(s), your involvement, current disposition, and the amount of settlement.

____ ____

I authorize the Council on Forensic Sciences (CFS) to consult with professional liability carriers, and other persons or entities to obtain information concerning my professional qualifications, including competence, ethics, and other qualifications. I, the undersigned hereby certify that the information requested by CFS, is truthful, correct, and complete in all respects, and I further understand that the intentional submission of false or misleading information or the withholding of relevant information is grounds for termination as a member of the CFS.The undersigned hereby agrees to notify CFS of any changes in the above information.

Member

Signature: ___________________________ Date:___________________

(No signature stamps!)


Payment Information

Annual membership to the Council on Forensic Sciences is $150.00. Payment can be made by credit card or personal check. All personal checks should be made out to the Council on Forensic Sciences.

Please circle your preferred payment method:

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Name of Applicant (Please Print)

College on Forensic Sciences - Membership
Signature of Applicant

College on Forensic Sciences - Membership
Date Signed

 

Please make sure all the necessary documents are enclosed (see checklist on page 1) and send your application to:

Clayton W. Hopkins, DC, DABFP
6231 66th Street North
Pinellas Park, FL 33781
Phone: 727-544-3330
Fax: 727-544-3221
Email: hclinic@tampabay.rr.com
Website: www.hopkinsclinic.com

Please note that membership in the Council on Forensic Sciences is contingent upon current membership in the American Chiropractic Association (ACA).

American Chiropractic Association Application

Apply for ACA Membership Online > https://www.acatoday.org/application/