LOUISIANA STATE BOARD OF MEDICAL EXAMINERS
LOUISIANA STATE BOARD OF MEDICAL EXAMINERS630 Camp St, New Orleans, LA 70130; (504) 568-6820Application for Certificate of Advanced PracticeSurgical Treatment of the AnkleQUALIFICATIONS FOR CERTIFICATION IN SURGICAL TREATMENT OF THE ANKLE:To be eligible for certification in the surgical treatment of the ankle, whether for initial licensure or annual renewal, an applicant who possesses and meets the qualifications and requirements of § l 305.A.1-5 of this Chapter shall:have completed a surgical residency approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association, consisting of:a three-year podiatric surgery residency (PSR 36) program or greater; ora three-year podiatric medicine and surgery residency (PM and S 36) program or greater; ora two-year podiatric surgery residency (PSR 24) program and:be board-certified in reconstructive rear foot and ankle surgery (RRA) by the American Board of Foot and Ankle Surgery (ABFAS), formerly the American Board of Podiatric Surgery (APBS); orbe board-certified in foot surgery and board qualified in reconstructive rear foot/ankle surgery (RRA) by the ABFAS.APPLICANTLast Name: ___________________________ First Name: ________________________ License Number: ___________________Mailing Address: __________________________________ City: _______________________ State: _______ Zip: ___________Phone: (_______) _____________________ Email: __________________________Signature: ________________________________________________ Date: _______/_______/_______POST GRADUATE TRAININGInstitution Name: ___________________________________________________ City: _____________________ State: _________ Date Started: _______/_______/_______ Date Completed: _______/_______/_______Three-year podiatric surgery residency (PSR 36) program or greater:Yes FORMCHECKBOX No FORMCHECKBOX Three-year podiatric medicine and surgery residency (PM and S 36) program or greater: Yes FORMCHECKBOX No FORMCHECKBOX Two year Podiatric Surgery Residency (PSR-24) Program:Yes FORMCHECKBOX No FORMCHECKBOX BOARD CERTIFICATION AND BOARD QUALIFICATIONBoard certified in reconstructive rear foot/ankle surgery:Yes FORMCHECKBOX No FORMCHECKBOX Board certified in foot surgery and board qualified in reconstructive rear foot/ankle surgery: Yes FORMCHECKBOX No FORMCHECKBOX MAIL TO: LSBME ? Attn: Podiatry ? 630 Camp St. ? New Orleans LA 70130 ? or FAX TO: 504-568-6823.*ALSO, contact the Council of Podiatric Medical Examiners and request a verification of your residency be sent directly to LSBME - phone 301-581-9200 x291 or fax 301-571-4903 AND contact the American Board of Podiatric Surgery and request verification of your Board Certification/Qualification be sent directly to LSBME - phone 415-553-7800 x125. ................
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