Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Alabama.
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116
Checklist for Physician Assistant and Anesthesiologist Assistant Initial License Application
Checklist
Online application
Complete all demographic information. Provide necessary explanations to questions answered yes. Provide education and activities since high school.
Application fee
$200
Fee must be paid during the online application process.
Criminal background check fee
$65
Fee must be paid during the online application process.
Criminal history release form
Form can be found on our website, www.albme.gov, and must be mailed to the Board along with your two completed fingerprint cards and copy of ID.
Two fingerprint cards
Fingerprint cards can be completed by most local law enforcement agencies. To request fingerprint cards, email [email protected].
Supporting documentation for Declaration of Citizenship
See List A and List B.
Copy of supporting documentation must be uploaded during the online application process.
Diploma reflecting graduation from an approved P.A./ A.A. training program
Transcripts are not acceptable.
Copy of diploma must be uploaded during the online application process.
NCCPA/NCCAA certificate/certification of successful completion of the examination
Copy of NCCPA/NCCAA certificate/certification of successful completion of the examination must be uploaded during the online application process.
Color photo
Photo must be taken within sixty days prior to the date of your application.
Photo must be uploaded during the online application process.
Primary source verification is required from any state that does not report data to the FSMB in which you have been certified, registered, or licensed as a P.A. or A.A. The verification must be requested by the applicant and sent directly from the related facility to the Alabama State Board of Medical Examiners.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Alaska.
To practice as a Physician Assistant - Certified, or to use the title, a person must be licensed under regulation 12 AAC 40.400 and authorized to practice under 12 AAC 40.408 by the State Medical Board. An approved Collaborative Plan must be on file with the State Medical Board in order to be authorized to practice.
The following documents must be on file with our office before the Board will consider your application for Physician Assistant CERTIFIED:
1. APPLICATION
A completed, signed application (pages 1-8)
2. FEES
Fees made payable to “State of Alaska”
Nonrefundable Application Fee: $200.00
Temporary/Provisional Permit Fee: $ 75.00
Permanent License Fee: $250.00
Collaborative Plan Fee (to establish or change): $125.00
Prescription Drug Monitoring Program (PDMP) Fee (optional): $ 25.00
3. AUTHORIZATION FOR RELEASE OF RECORDS
A completed Authorization for Release of Records form (#08-4226a).
4. DIPLOMA
A certified true copy of diploma from an accredited Physician Assistant program (accredited by the Accreditation Review Commission on Education for the Physician Assistant or, before 2001, by its predecessor accrediting agency the American Medical Association’s Committee on Allied Health Education and Accreditation).
5. VERIFICATION OF PHYSICIAN ASSISTANT PROGRAM EDUCATION
A completed Verification of Physician Assistant Program Education form (#08-4226c)
6. NCCPA CERTIFICATE
A certified true copy of current certification by the National Commission on Certification of Physician Assistants.
7. DEA Registration Certificate
A copy of your current DEA registration certificate.
8. COLLABORATIVE PLAN
An approved plan of collaboration with a physician licensed to practice in the State of Alaska (#08-4226d)
9. VERIFICATION OF LICENSURE
Verifications of Licensure from all licensing jurisdictions where you have ever been licensed (#08-4226b)
10. FSMB Clearance Report
A completed clearance report from the Federation of State Medical Boards (#08-4226f)
11. DEA Clearance Report
A completed clearance report from the Drug Enforcement Administration (#08-4226h)
A certified true copy of your current NCCPA certificate must be maintained in your license file at all times, as well as a current copy of your DEA registration. Without those documents, you are not in compliance with regulations and may not practice.
08-4226 (Rev. 2/3/2021) Application Instructions Page 1 of 5
Alaska State Medical Board
PO Box 110806, Juneau, AK 99811-0806
(907) 465-2550
Email: [email protected]
Website: ProfessionalLicense.Alaska.Gov/StateMedicalBoard
Application for Physician Assistant (PA)
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Arizona.
Checklist for an Initial Physician Assistant License Application
Please do not submit this form with your application. Keep it for your records.
APPLICATION FEE
Application Fee
The application fee is $125 payable by check or credit card. The application fee must be submitted with the application and is non-refundable.
License Fee
Once your license application is approved, you will be required to pay a prorated licensure issuance fee up to $370. This fee is prorated based on your birth month.
LICENSE APPLICATION
Completed Application
Provide a complete application, pages 1 - 8. You must complete all questions. If you fail to complete a question, your application will be considered deficient and the processing of your application will be delayed.
EVIDENCE OF LEGAL STATUS
A photocopy of Your Birth Certificate or Passport
Applicants must provide a photocopy of a Birth Certificate or Passport.
Proof of Immigration status
A list of the documents that are required to be submitted to the Board is included with the application.
Government Issued Photo ID
A copy of a government issued photo ID is required if the proof of legal status does not include a photo. Example: driver license or state I.D.
Evidence of legal name change
Applicant must provide evidence of legal name change, if applicable. Example: Marriage Certificate, court documents showing legal name change.
EDUCATION
Education Certification Form
The applicant must send the education certification form provided with the application packet, to the program in which the applicant received a physician assistant degree. This form must be completed, signed and sent directly to the Board by the program.
NCCPA EXAMINATION
NCCPA
Applicants must request a copy of the applicant's certificate of successful completion of the NCCPA examination and the applicant's examination score to be sent directly to the Board from NCCPA.
VERIFICATION OF OTHER STATE LICENSE(S)
State/Province Licensure Verification
License verification is required to be sent directly to the Board from each state or province in which you hold or have held a license. If you obtain a license during the licensure process, you must request the verification to be sent directly to the Board. *The Board accepts verifications from Veridoc.
Revised 8-27-2019
HOSPITAL AFFILIATIONS/EMPLOYMENT
Hospital Affiliations/ Employment Verifications
You must request verification(s) of all hospital affiliations and employment for the five years preceding the application to be sent directly to the Board. Each hospital must verify the applicant's affiliation or employment on the hospital's official letterhead or the electronic equivalent.
MALPRACTICE DOCUMENTS
Malpractice Form
If an applicant has a malpractice settlement or judgment against the applicant within 10 years from the date of the application, the applicant must complete a malpractice form, included with the application packet, for each malpractice settlement or judgment against the applicant. Please do not submit this form if you have not had a malpractice settlement or judgment against you within the last 10 years.
QUESTIONNAIRE AFFIRMATIVE RESPONSES
Narrative and Supporting Documents
If you answer "yes" to a question on the questionnaire page, please provide the following:
•A narrative/explanation of the circumstances that led to the issue disclosed.
•Documents to support your narrative. Example: Court documents, Board Orders, etc.
*If documents are not provided, this will delay the application process.
Please note: It is the applicant's responsibility to report to the Board any changes that may have occurred during the application process. Failure to report any adverse actions to the Board during the licensure process may result in denial or revocation of your license.
Information requested to be sent directly to the Board can be sent to the following:
DO NOT EMAIL APPLICATION(S)
Email: [email protected]
Arizona Regulatory Board of Physician Assistants 1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Arkansas.
ARKANSAS MEDICAL PRACTICES ACT, 17-105-102 (b) AND RULE 24: THE BOARD MAY GRANT A LICENSE AS A PHYSICIAN ASSISTANT TO AN APPLICANT WHO:
(1) Submits an application on forms approved by the board;
(2) Pays the appropriate fees as determined by the board;
(3) Has successfully completed an educational program for physician assistants or surgeon assistants accredited by the Committee on Allied Health Education and Accreditation or by its successor agency and has passed the Physician Assistant National Certifying Examination (PANCE) administered by the National Commission on Certification of Physician Assistants (NCCPA).
(4) Certifies that he or she is mentally and physically able to engage safely in practice as a Physician Assistant;
(5) Has no licensure, certification, or registration as a Physician Assistant under current discipline, revocation, suspension, or probation for cause resulting from the applicant’s practice as a Physician Assistant, unless the board considers such condition and agrees to licensure;
(6) Submits to the board any other information the board deems necessary to evaluate the applicant’s qualifications;
(7) Has been approved by the board;
(8) Is at least twenty-one (21) years of age; and
(9) After July 1, 1999, has at least a bachelor’s degree in some field of study from a regionally accredited college or university, unless the applicant has:
(A) Prior service as a military corpsman and is a graduate of a Physician Assistant education program recognized by the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs or the applicant is currently certified by the National Commission on Certification of Physician Assistants.
(B) Was serving as a Physician Assistant in a federal facility located in the State of Arkansas on or after July 1, 1999, and who is a graduate of a Physician Assistant education program recognized by the Committee on Allied Health Education Programs;
(C) Was licensed in good standing on July 30, 1999, by the Arkansas State Medical Board; or
(D) Was enrolled on or before July 1, 1999 in a Physician Assistant program recognized by the Commission on Accreditation of Allied Health Education Programs.
LICENSURE IS BY CREDENTIALS:
Credentials must be verified from the originating source; verifications received from applicants will be returned
LICENSING EXAMINATIONS MEETING THE BOARD REQUIREMENTS ARE AS FOLLOWS:
Physician Assistant National Certifying Examination (PANCE)
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in California.
INITIAL APPLICATION FOR PHYSICIAN ASSISTANT LICENSURE
- Application Instructions and General Information
- Initial Physician Assistant Application for Licensure (Paper format)
- Online Physician Assistant Application for Licensure
REQUIRED DOCUMENTS FOR PHYSICIAN ASSISTANT LICENSURE
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Colorado.
Licensing Requirements Qualifications for Physician Assistant Licensure
Physician Assistants (PAs) are persons who have completed a graduate training program in health care. PAs are licensed by the Medical Board and work under the supervision of a physician. The Medical Board rules allow PAs to perform any medical function delegated to them by the supervising physician including full prescribing privileges.
Requirements for licensure as a physician assistant include:
·Graduation from an NCCPA-approved physician assistant program;
·Verified practice history;
·Passage of the NCCPA National Board Exam;
·Verification of Federation of State Medical Boards disciplinary history.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Connecticut.
Licensure Application Fee All fees are subject to review and change on July 1 each year. The application fee is not refundable. This fee covers the cost of processing the application and the licensing fee until the next renewal period. All physician assistant licenses expire on January 31 of even-numbered years.
In order to qualify for licensure, an applicant must meet the following eligibility requirements:
Hold a baccalaureate or higher degree in any field from a regionally accredited institution of higher education;
Graduated from a physician assistant program accredited, at the time of graduation, by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA);
Please note that recent graduates of an accredited physician assistant program are eligible for a temporary permit. Please note that a temporary permit is not available to licensees applying from other states or for applicants applying for reinstatement of a lapsed Connecticut license.
Passed the certification examination of the National Commission on Certification of Physician Assistants, Inc. (NCCPA);
Holds current certification by the NCCPA;
Has completed not less than sixty (60) hours of didactic instruction in pharmacology for physician assistant practice in an accredited physician assistant education program or a post-graduate program for physician assistant practice.
Documentation Requirements
Applicants must arrange for submission of the following documents directly to the Department from the source:
An official transcript, sent directly from the educational institution to this Department, verifying the award of a baccalaureate or higher degree;
An official transcript sent directly from the educational institution to this Department verifying graduation from an accredited physician assistant program;
Official verification sent directly from the NCCPA of successful completion of the examination and of current certification status;
Official verification, sent directly from the educational institution, post-graduate program provider, NCCPA or American Academy of Physician Assistants to this Department, of completion of not less than sixty (60) hours of didactic instruction in pharmacology for physician assistant practice. Please select this link for the required form; and
If applicable, official verification form sent directly from each state licensing authority where a license or certification is or has ever been held. Please note that some jurisdictions charge a fee for this service. Please contact the jurisdiction directly for fee information.;
A completed application with photograph attached. Applications are only accepted online. Please select this link to apply online. The application fee is $190.
Please arrange for all supporting documentation to be sent directly from the source to:
Connecticut Department of Public Health
Physician Assistant Licensure
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Delaware.
In addition to submitting the application and fee in DELPROS, you must submit:
- State/Jurisdiction Licensure Verification sent directly to the Board office from each state or jurisdiction in which you currently hold or have ever held a license. Verifications that you print off the internet or receive by fax will not be accepted.
- If the jurisdiction utilizes VeriDoc to process their license verifications, you must request the verification from VeriDoc. VeriDoc will send the verification directly to the Board office. For a list of participating states, click
VeriDoc Participating States.
- If the jurisdiction utilizes VeriDoc to process their license verifications, you must request the verification from VeriDoc. VeriDoc will send the verification directly to the Board office. For a list of participating states, click
-
- If you have ever held an Indiana license, request a digitally certified verification at Indiana License Verification. Upload the digitally certified verification directly to your DELPROS application.
-
- If you hold a license in a jurisdiction that does not provide an official license verification directly to the Board office, you must upload the jurisdiction’s digitally certified verification directly to your DELPROS application. A copy of the license certificate will not be accepted.
-
- For all other jurisdictions, request the jurisdiction to send the official license verification directly to you, then upload the jurisdiction’s license verification directly to your DELPROS application. A copy of the license certificate will not be accepted.
- State of Delaware and Federal Bureau of Investigation criminal background checks (CBC). Follow the instructions on the Criminal History Record Check Authorization form to arrange to be fingerprinted. Submit the forms and payment to the State Bureau of Identification (SBI). Do not send these forms to the Board office.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in District of Columbia.
PA Check List
Authorization to release information form
Two recent and identical passport type photos of the applicant's face with the applicant's name printed on the back
One photocopy of current government issued photo ID
Criminal background check
Three character reference forms
Verification of licensure
PA school transcripts
Examination Scores
Delegation Agreements
Malpractice claims form
National Practitioner Databank Self Query Report
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Florida.
Applicants to become a licensed Physician Assistant must meet the following requirements:
- Be a graduate of a physician assistant training program accredited by the Commission on Accreditation of Allied Health Programs or its successor organization.
- Passed the proficiency examination administered by the National Commission on Certification of Physician Assistants (NCCPA)
- Hold a current certificate issued by the NCCPA. If an applicant does not hold a current certificate issued by the NCCPA and has not actively practiced as a physician assistant within the immediately preceding 4 years, the applicant must retake and successfully complete the entry-level examination of the NCCPA.
- Complete application
- Pay fees
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Georgia.
APPLICANTS MUST SUBMIT EITHER:
**FOR LICENSURE ONLY: ● Pages 1- 4 – Initial Physician Assistant Application.
OR
**FOR LICENSURE AND APPROVAL OF PRIMARY SUPERVISING PHYSICIAN: ● Page 1-4 – Initial Physician Assistant Application.
● Page 5 - Utilization of a Physician Assistant
● Form E - Basic Job Description – Physician Anesthesiologist Assistant
OR
● Form F - Basic Job Description – Physician Assistant – Primary Care.
Must be ORIGINAL SIGNATURE by the applicant and the primary supervising physician. Supervising physician must also list all alternate supervising physicians, if applicable.
ALL APPLICANTS MUST ALSO SUBMIT:
• Form A - Affidavit of Applicant
Must be signed, dated and notarized.
The applicant and notary signature dates must match.
A current photograph that is 2”x2”, head and shoulders only, and not more than six months old. Attach photograph to Affidavit.
• Form A2-Affidavit of Citizenship
Must be signed, dated and notarized.
Must provide proof that you are a United Stated Citizen, a legal permanent resident of the United States, or a qualified alien or non-immigrant under the Federal Immigration and Nationality Act.
Verifiable Document. Send along with your Notarized Affidavit, at least one secure and verifiable document. For a listing of acceptable verifiable documents, see Page 2-3 of Form A2.
Please be sure that copies of any submitted documents are legible. All information on document must be legible. If we cannot read what you have submitted, we will be unable to submit your information to the SAVE program, which will delay the consideration of your application.
• Form C (AA) OR Form D (PA)– Reference Form
Applicants must provide at least two (2) current references, addressed to the Board, and must be from licensed physicians, other than proposed employer and/or director of training program, who have supervised you. Applicants downloading application forms from our web site must download two (2) copies of the Physician Assistant Reference Form. Forms MUST have original receipt.
2
New AA/PA Graduate Licensure Application General Information and Checklist
• Form G – Request for Verification of Certification (AA)
Submit this form to NCCAA. Please ask the school to complete this form and mail directly to the Georgia Composite Medical Board.
• Request for Verification of Certification (PA)
Applicant must go to NCCPA.net and request certification verification be mailed to the Georgia Composite Medical Board.
• Form K - Certificate of Education For Physician Assistants
Submit this form to your school. Please ask the school to complete this form and mail directly to the Georgia Composite Medical Board.
• Resume - Current CV of activities, education, certifications, etc.
• Form J – Specific Power of Attorney (OPTIONAL)
Authorizes your designee to make inquires to the Board regarding your application.
Must be submitted with Initial Application.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Hawaii.
REQUIREMENTS AND INSTRUCTIONS - PHYSICIAN ASSISTANT
Access this form via website at: cca.hawaii.gov/pvl
APPLICANTS ARE SUBJECT TO REQUIREMENTS IN EFFECT AT THE TIME OF FILING.
APPLICATION FOR LICENSURE
Complete the on-line fillable form or print legibly in black ink. Sign the application.
SOCIAL SECURITY NUMBER
Your Social Security Number is used to verify your identity for licensing purposes and for compliance with the below laws. For a license to be issued, you must provide your Social Security Number or your application will be deemed deficient and will not be processed further. The following laws require that you furnish your Social Security Number to our agency:
FEDERAL LAWS: 42 U.S.C.A. §666(a)(13) requires the Social Security Number of any applicant for a professional license or occupational license be recorded on the application for license; and If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security Number as part of the mandatory reporting we must do to the Healthcare Integrity and Protection Data Bank (HIPDB), of any final adverse licensing action against a licensed health care practitioner. HAWAII REVISED STATUTES ("HRS"): §576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational license be recorded on the application for license; and §436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security Number if the licensing authority is authorized by federal law to require the disclosure (and by the federal cites shown above, we are authorized to require the Social Security Number).
FEES
Attach appropriate fee payable to: COMMERCE & CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a U.S. financial institution.)
If you wish to be licensed during this period, pay:
February 1, even-numbered year through January 31, odd-numbered year . . . . . . . . . . . . . . . . . . . $182 (Application fee - $20*, License fee - $32, Compliance Resolution Fund - $110, 1/2 renewal for second year of two-year license period - $20)
If you wish to be licensed during this period, pay:
February 1, odd-numbered year through January 31, even-numbered year . . . . . . . . . . . . . . . . . . . $107** (Application fee - $20*, License fee - $32, Compliance Resolution Fund - $55)
*The application fee is not refundable. **Subject to renewal January 31, even-numbered year regardless of issue date.
NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service charge shall be assessed for payments that are dishonored for any reason.
If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing must be directed to the agency that denied your application, and must be made within 60 days of notification that your application for a license has been denied.
(CONTINUED ON PAGE 2)
AMD-00 1016R
FEDERATION REPORT
ARRANGE to have the Federation Discipline Report sent directly to the Hawaii Medical Board (HMB). Email the "Federation Discipline Report" form (MD-04) to the Federation of State Medical Boards (Federation - [email protected]) and request that they send the form directly to the HMB.
RELEASE OF INFORMATION
If an agency or individual is assisting you with the licensure process, we will not be able to release any information to them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of Information to Third Party, sign and date it.
EDUCATION
ATTACH a copy of your certificate from the institution where you completed a training program for physician assistant.
ARRANGE to have the National Commission on Certification of Physician Assistants (NCCPA) send a verification of current certification to the HMB.
NCCPA may be contacted at: NCCPA Phone: (678) 417-8100 1200 Findley Rd., Suite 200 Fax: (678) 417-8135 Duluth, GA 30097 www.nccpa.net
VERIFICATION OF LICENSE
On the application, list all the licenses you hold or held.
ARRANGE to have verification of licensure sent directly to the HMB. To do this, contact all the jurisdictions that you are/were licensed in and request that they send a verification of licensure directly to the HMB.
VERIFICATION OF SUPERVISING PHYSICIAN
ATTACH a completed verification form signed by you and your supervising physician who must be currently licensed in Hawaii. This form may be duplicated as needed.
FILING DEADLINE
Submit all required items (application, fees and supporting documents) at least 20 business days prior to employment starting date.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Idaho.
PHYSICIAN ASSISTANT APPLICATION INSTRUCTIONS
FEES
• Application Fee - $100
o Mail application fee with application.
o Payment can be by check, money order (payable to IDAHO STATE BOARD OF MEDICINE), or credit card
(Credit Card Transmittal Form included)
• Payment of licensure fee and prorated renewal fee will be required after application approval.
o After approval, a letter will be emailed to Applicant indicating the remaining fees due.
• Application and all license fees are non-refundable.
FINGERPRINT CARD
• Once application fee has been received, a fingerprint card will be mailed to Applicant and processing of the
application will begin.
• Take to local law enforcement office.
o Applicant must use the fingerprint card provided by the Board of Medicine.
• Return fingerprint card with Fingerprint Statement (included in fingerprint card packet).
o Per the requirements of the FBI, fingerprint cards cannot have any third-party involvement and can
only be mailed to and returned from Applicant's personal address.
APP1
• Check the box for either Physician Assistant or Graduate PA (has graduated but has not passed National Exam).
• Complete all sections.
• If Applicant has not applied for registration/licensure in other states, write “Not Applicable” in the appropriate
section.
APP2
• Complete all sections.
• History cannot have any gap of more than one month. Attach additional sheets for history, if necessary.
• Answer all questions 1-8.
o Provide details, for YES answers, on a separate sheet.
o YES answers will require additional documentation (DD-214, court documents, etc.).
• Application must be signed by Applicant and notarized by a notary public.
The above items cannot be faxed or emailed.
The items listed below are to be requested by Applicant and can be faxed or emailed.
FAX: 208-327-7005; Email: [email protected]
EDU1 (VERIFICATION OF PHYSICIAN ASSISTANT PROGRAM)
• Complete Applicant section only.
• Form must be signed by Applicant.
• Send this form to institution where Applicant completed their baccalaureate degree.
o Registrar must return completed form AND transcripts directly to the Board of Medicine.
EDU2 (VERIFICATION OF EDUCATION)
• For PA Certificate program graduates only.
o Graduates from PA Baccalaureate or Masters programs are not required to complete this form.
• Complete Applicant section only.
• Form must be signed by Applicant.
• Send this form to institution where Applicant completed their Baccalaureate or Masters degree.
o Registrar must return completed form AND transcripts directly to the Board of Medicine.
NATIONAL EXAM VERIFICATION
• Applicants for full PA licensure must request verification from the NCCPA.
o NCCPA Website: www.nccpa.net
• Verification must be sent from the NCCPA directly to the Board of Medicine.
VERIFICATION OF REGISTRATION/LICENSURE
• Required from all states in which Applicant holds or has held licensure/registration.
• Verification must be sent from the state of licensure directly to the Board of Medicine.
SSN1 (DISCLOSURE OF SOCIAL SECURITY NUMBER)
• Check the box for either “do” or “do not”.
• Complete all sections.
• Form must be signed by Applicant.
AUTH1 (Authorization for Release of Information)
• Required to release information to individual(s) other than Applicant.
• Must be signed by Applicant and notarized by a notary public.
No
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Illinois.
PA Licensing
Complete the Application
Submit official transcripts
Evidence of successful completion of the PANCE
Certification of Licensure
Pay required fees
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Indiana.
Physician Assistant Licensure Application
You must complete, date and sign the application for licensure. All information must be completed on the application or have N/A for not applicable. An email address is mandatory. All correspondence regarding the status of your application will be sent via email, as well as all future license renewal information.
If you have not secured employment, you do not need to complete or send in the Collaborating Physician page of the application, nor do you need to submit a collaborative agreement. A license may be issued without both. Once you obtain employment you must then complete a change/addition application, submit it with payment and a collaborative agreement. You will not be able to practice until we have a collaborative agreement on file. Initial licenses issued 90 days before the renewal date of all licensees do not expire until the next renewal cycle. If you have any questions concerning this please feel free to contact the Committee staff.
Documents Required for Licensure
Photograph - Submit one (1) passport quality photo taken within the past eight (8) weeks.
Application Fee - Please submit an application fee in the amount of $100.00 payable to Professional Licensing Agency. All fees are non-refundable and non-transferable.
Notarized Copy Information - When submitting a notarized copy of an original document, the notary must make a statement to the fact that the notary has seen the original document. If this is not done the document will not be accepted.
Positive Responses - If you have answered any of the questions on the application “yes” you must submit a notarized affidavit detailing the occurrence/situation, the outcome, date of occurrence, if it is a malpractice payment include the amount paid in your behalf. An affidavit is not needed if you responded to Question #12 regarding employment history. If applicable please submit copies of all court documents and/or arrest records. Letters from attorneys or insurance companies are not accepted in lieu of your statement; however they may be included with your statement.
Criminal Background Checks - Any physician assistant seeking initial licensure are required to submit to fingerprinting and a national criminal background check by the Indiana State Police. The individual applicant will be responsible for the cost of the background check. The backgrounds must be done by the state approved vendor and any checks done outside the chain of command will not be accepted. Information on how to be fingerprinted and a list of frequently asked questions, go to criminal background check information.
Official Transcript - Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been confirmed.
Score Report - You must request that your official score report be sent directly to Professional Licensing Agency from the NCCPA.
National Commission on Certification
of Physician Assistants
12000 Findley Road, Suite 200
Duluth, GA 30097
(678) 417-8100
(678) 417-8135 (fax)
Email: [email protected]
Website: http://www.nccpa.net/
NCCPA Certificate - Submit a notarized copy of your current NCCPA certificate.
Verification of State Licensure(s) - You must request a “License Verification or Letter of Good Standing” from each State/Country in which you currently are or have ever been licensed, certified, or registered in any regulated health profession or occupation. This includes all licenses, etc., that are active, expired, inactive, retired, delinquent etc. In addition to any physician assistant license/certification etc., this also pertains to any professional health license such as an EMT, nurse, pharmacist, etc. You will need to print off the verification form and contact the appropriate entities/states regarding their process. They may charge a fee for this service. They will need to complete the verification and mail it directly to our office. Many states use their own computer generated document, in lieu of our form, which is acceptable. We do accept official web verifications; the verification must come directly from the State in which you were licensed.
Collaborative Agreements - Click here for information on collaborative agreements.
Controlled Substances - Click here for information on applying for a controlled substance registration.
Chart Review & Supervision
- The review of patient encounters will require review within 10 days for the following:
* 1st year- 10%
* Subsequent years- percentage collaborating physician determines to be reasonable as stated in the collaborative agreement
IC 25-27.5-6-1
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Iowa.
Physician Assistant
Documentation Required for Licensure
¨ Application and fee. All application fees are nonrefundable. To apply, do the following:
Create an account, apply and pay online at: https://ibplicense.iowa.gov/
¨ Supervising Physician Names –
Supervising physicians may be added to your online record 24 hours a day, 7 days a week through the Board’s online services webpage at: https://ibplicense.iowa.gov/mystatus. Use your @iowaID account and password to sign in. Click on the More Info link located at the bottom left of the My Licenses screen, under the Action column. Click on the Edit link located on the right side of the screen under Supervision. Read the Instructions posted on the License Detail – Process screen. Use the Add and Save buttons.
¨ Educational Requirement –
Official academic transcripts verifying graduation from a program for education and training of physician assistants that is accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation, the Commission on Accreditation of Allied Health Educational Programs, or by the Accreditation Review Commission on Education for the Physician Assistant, sent directly to the Board office from the college or university. Applicants that passed the NCCPA initial certification exam prior to 1986 are exempt from the accredited program graduation requirement. Foreign-trained applicants should contact the Board office for educational requirements.
¨ NCCPA Certification Requirement –
Proof of initial certification from the NCCPA, sent directly to the Board office from the NCCPA.
¨ If the applicant has previously been licensed in another state he/ she must also provide one of the following:
1. Copy of current certification from the NCCPA, sent directly to the Board office from the NCCPA, OR
2. Proof of completion of 100 CME hours for each biennium since initial certification.
¨ Verification of licenses held in other states (if any):
Applicants that have been previously licensed, registered or certified in any other state must provide official verification of licensure in the other state(s). The license verification must include license issue date, expiration date and any pending or past disciplinary action. The verification may be printed from another state licensing board’s website if it contains all of the required information. If web based verification is not available, the verification must be send directly to the Board office by the state(s) where the applicant has been licensed, registered, or certified. If the applicant has never been licensed in another state, ignore this item.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Kansas.
PA Licensure
Complete Application
NCCPA Certification
Licensure Verification form
Certificate of Professional School
Photo
Signed Oath
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Kentucky.
311.844 Licensing of physician assistants -- Requirements -- Endorsement from other state -- Renewal of license -- Continuing education.
(1) To be licensed by the board as a physician assistant, an applicant shall:
(a) Submit a completed application form with the required fee;
(b) Be of good character and reputation;
(c) Be a graduate of an approved program; and
(d) Have passed an examination approved by the board within three (3) attempts.
(2) A physician assistant who is authorized to practice in another state and who is in good standing may apply for licensure by endorsement from the state of his or her credentialing if that state has standards substantially equivalent to those of this Commonwealth.
(3) A physician assistant's license shall be valid for two (2) years and shall be renewed by the board upon fulfillment of the following requirements:
(a) The holder shall be of good character and reputation;
(b) The holder shall provide evidence of completion, during the previous two (2) years, of a minimum of one hundred (100) hours of continuing education approved by the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American Academy of Physician Assistants, or by another entity approved by the board. The one hundred (100) hours of continuing education required by this paragraph shall include:
1. During the first two (2) years of licensure or prior to the first licensure renewal:
a. One (1) continuing education course on the human immunodeficiency virus and acquired immunodeficiency syndrome; and
b. One and one-half (1.5) hours of continuing education in the prevention and recognition of pediatric abusive head trauma, as defined in KRS 620.020; and
2. If the license holder is authorized, pursuant to KRS 311.858(5), to prescribe and administer Schedule III, IV, or V controlled substances, a minimum of seven and one-half (7.5) hours of approved continuing education relating to controlled substance diversion, pain management, addiction disorders, use of the electronic system for monitoring controlled substances established in KRS 218A.202, or any combination of two (2) or more of these subjects; and
(c) The holder shall provide proof of current certification with the National Commission on Certification of Physician Assistants.
Effective: June 29, 2021
History: Amended 2021 Ky. Acts ch. 70, sec. 1, effective June 29, 2021. -- Amended 2020 Ky. Acts ch. 39, sec. 2, effective July 15, 2020. -- Amended 2015 Ky. Acts ch. 113, sec. 7, effective June 24, 2015. -- Amended 2010 Ky. Acts ch. 171, sec. 11,
effective July 15, 2010. -- Amended 2006 Ky. Acts ch. 78, sec. 3, effective July 12, 2006. -- Created 2002 Ky. Acts ch. 130, sec. 25, effective July 15, 2002.
Legislative Research Commission Note (7/12/2006). 2006 Ky. Acts ch. 78, sec. 11, provides: "A physician assistant who is certified in Kentucky and in good standing on the effective date of this Act [July 12, 2006] shall automatically be licensed under Sections 1 to 10 of this Act [KRS 311.840, 311.842, 311.844, 311.845, 311.846, 311.848, 311.850, 311.852, 311.856, and 311.862] and shall be issued a physician assistant license upon annual renewal."
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Louisiana.
Application & Instructions for Initial Licensure - Physician Assistant
Log in to LaMED DashBoard to begin a new online initial application, complete a previously started (and saved) online initial application or to check the status of your completed online initial application.
To access a paper application, click HERE (available for a limited time)
The items listed below MUST be completed and mailed to the LSBME as part of the initial application process.
Note: notarized documents must be signed in the presence of a notary.
- Oath or Affirmation- must be notarized
- Third Party Authorization- must be notarized
- Photograph Page - passport quality
- Statement of Legal Name
- FCVS Application
- Background Check
Oath or Affirmation
This form must be notarized. All yes answers must be accompanied by a sworn affidavit. A sworn affidavit is an explanation (in applicant’s own words) that must be typed and notarized. Note: If criminal history is found that was not disclosed, you will be required to submit a new Oath or Affirmation, a notarized affidavit as to why you did not disclose the information and a new processing fee equal to the initial licensure fee. It is important that you answer question 3 accurately and truthfully. Do not take the advice of friends, lawyer, etc.
Third Party Authorization
This form must be notarized. It authorizes LSBME to obtain information concerning the applicant from third parties.
Photograph
A passport quality photograph must be submitted. This photo must be a 2"x2" clear, head and shoulders photo taken within the last 6 months.
FCVS
You must complete the FCVS application in order to apply for licensure.
Background Check
LSBME conducts background checks as part of the application process. Instructions and forms can be found at the link above.
Additional Requirements
Fee
Licensure: $275.00.
Fee must be paid via credit/debit card (Visa, MasterCard or Discover only) if applying online.
Fee must be paid via Personal check/money order if sending in a paper application.
Fee is non-refundable.
Birth Certificate/Valid Visa
- S. born citizen - submit a notarized copy of birth certificate
- S. citizen not U.S. born - submit notarized copy of proof of citizenship (ie certificate of citizenship or consular report of birth abroad). Naturalized citizen - submit a notarized copy of birth certificate and notarized Certificate of Naturalization.
- Non U.S. citizen - submit a notarized copy of birth certificate and notarized current Visa issued by the U.S. Citizenship and Immigration Services. (Acceptable Visas: H1B, J1, O1, NAFTA-TN or Employment Authorization, or Permanent Resident)
Marriage Certificate/Name Change
Application for certification in a name other than what appears on the birth certificate requires a notarized copy of official documentation of name change (ie marriage certificate).
Notarization as a “True Copy”
Request the notary to certify a copy of your birth certificate and/or marriage certificate as a “true and correct copy of the original”. If the notary will not notarize the copy,
you can attest that it is a “true and correct copy of the original”. The notary can then notarize your signature.
NCCPA - National Commission on Certification of Physician Assistants www.nccpa.net; (678) 417-8100
Licensure Applicants
licensure applicants must be currently certified by NCCPA. Applicant must request initial PANCE score report be sent directly to LSBME.
Temporary Licensure Applicants
to be issued a temporary license all requirements for licensure must be met except that the applicant has not yet taken or is awaiting the results of the examination. After examination the applicant must request a score report be sent directly from NCCPA to LSBME.
Verification of Other Licenses
Verification of all state licenses are required. Contact the state board(s) directly to obtain verification of your license. Please note, there may be a processing fee needed.
Online Education Course and Quiz
Take and successfully complete the Online Education Course and Quiz. This course will review the Rules pertaining to the practice of physician assistants in the state of Louisiana. Instructions and enrollment key will be provided upon receipt of application.
Other Information
Verification of Application/Licensure Status
Visit our website at www.lsbme.la.gov and log on to your account to verify the progress/status of your application.
Communication with the Board
Mailing Address - LSBME, 630 Camp Street, New Orleans, LA 70130
Questions - Contact our licensing department at [email protected]. To find the analyst directly assigned to your application, click on Contact Us.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Maine.
TO BE CONSIDERED FOR LICENSURE IN THE STATE OF MAINE, AN APPLICANT MUST SATISFY
THE FOLLOWING REQUIREMENTS:
1. Submit an administratively complete application on forms approved by the Board;
2. Pay the appropriate uniform licensure fee ($300);
3. Have successfully completed an educational program for physician assistants accredited by the American
Medical Association Committee on Allied Health Education and Accreditation, or the Commission for
Accreditation of the Allied Health Education Programs, or their successors;
4. Have no license, certification or registration as a physician assistant, or any other type or classification of
health care provider license, certification or registration under current discipline, revocation, suspension,
restriction or probation;
5. Have no cause existing that may be considered grounds for disciplinary action or denial of licensure as
provided by law;
6. Pass, at the time of license application, a jurisprudence examination administered by the Board; and
7. Have passed the NCCPA certification examination and holds a current certification issued by the NCCPA
that has not been subject to disciplinary action by the NCCPA at the time the license application is acted
upon by the Board.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Maryland.
PA Licensure
Complete Application
Verification of Professional Education
Verification of Bachelor's Degree
NCCPA verification
Oral and Written Competency in English
Verification of Other State Licenses
Photo
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Massachusetts.
Complete applications must include the following documents:
Completed application form, signed and dated by the applicant and notarized.
2x2 passport style color photo; white or off-white background; copies and printer generated photos are not acceptable.
Signed and notarized Criminal Offender Record Information (CORI) Acknowledgement Form obtained from the Board’s website.
Check or money order payable to the Commonwealth of Massachusetts for $225.00; cash or foreign currency is not accepted.
NOTE: If you hold a Temporary Practice Certificate, you must pay this fee in addition to the fee previously paid for your Temporary Practice Certificate.
Official transcripts in signed, sealed envelopes from physician assistant programs/degrees with proof of a bachelor’s degree or higher. When requesting official transcripts, please inform each school’s registrar that the transcript must be complete and indicate the degree and date conferred in mm/dd/yyyy format.
NOTE: If transcripts have been previously submitted with an application for a Temporary Practice Certificate, they do not need to be resubmitted, if they were submitted within the past 12 months.
NCCPA documentation of certification is required. This must be sent directly from NCCPA. On-
line verification is acceptable.
Verification of licensure status, in signed, sealed envelopes, or via on-line primary source verification from any state or jurisdiction in which you now or have ever held any professional license or board certification. Verifications must be sent directly to the Board by the state or other jurisdictions.
For Massachusetts licenses only, the Board also accepts printed, self-queries of online verification of licensure from the following: Board of Registration in Dentistry, Board of Registration in Nursing, Board of Registration in Pharmacy, Board of Certification of Community Health Workers, Board of Registration of Genetic Counselors, Board of Registration in Naturopathy, Board of Registration of Nursing Home Administrators, Board of Registration of Perfusionists, Board of Registration of Respiratory Care, Nurses Aid Registration Board and the Office of Emergency Medical Services for EMT, Advanced EMT and Paramedic Certification. Any printed, self-queries of online verification of licensure must be submitted with the application packet.
Completed MassHealth Attestation form.
NOTE: If verifications have been previously submitted with an application for a temporary practice certificate, they do not need to be resubmitted if they were issued within the past 12 months.
□ Submission of completed application and fee acknowledges that the applicant understands and agrees to all provisions herein. Applications are void if requirements for physician assistant licensure are not met within one (1) year from the date of Board receipt of this application. All fees are non-refundable and non-transferable.
□ Application must be submitted on single-sided paper.
Retain a copy of the completed application for licensure for your records. The Board is not able to provide copies of the application. Employers may require that you provide them with a copy.
All submissions and documentation for agenda items must be received by the Board at the close of business on the Monday of the week preceding the scheduled Board meeting. Materials received after the deadline will be reviewed prior to being placed on the agenda for the next scheduled meeting.
*A Supervising Physician and Work Setting Information form must be on file with the Board within thirty (30) days of beginning employment. Your license may be issued without these forms, though they have been included for your convenience.
NOTE A: If there has been no change in supervising physician[s] and/or work setting[s] since a Temporary Practice Certificate was issued, new forms do not need to be resubmitted.
NOTE B: Multiple supervising physicians and work settings require submission of separate forms for each supervising physician and each work setting.Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Michigan.
MICHIGAN PHYSICIAN’S ASSISTANT (PA) LICENSING GUIDE
LICENSURE REQUIREMENTS CHECKLIST
(Listed below are the minimum requirements needed to obtain a physician’s assistant license.)
APPLICATION AND FEES
Online Application for a Physician’s Assistant License - Complete all fields, answer all questions, and upload any supporting documentation.
Online Application for Controlled Substance License (Optional)
Online applications can be completed by visiting www.michigan.gov/miplus
Application Fee + 2 year license fee: (Must be paid by Visa, Mastercard, American Express, or Discover credit or debit card)
PA by Exam or Endorsement $156.70
PA Temporary $37.80
Controlled Substance $173.00
If you will be prescribing, dispensing, manufacturing, or distributing controlled substances, you must apply for both a physician’s assistant and controlled substance license. You may apply for a controlled substance license by completing the controlled substance license fields in the application. If you do not apply for a controlled substance license on your physician’s assistant application, you must wait for the physician’s assistant license to be issued before you may apply for a controlled substance license.
Effective September 1, 2019, an individual seeking a controlled substance license or who is licensed to prescribe or dispense controlled substances must have completed a 1-time training in opioids and controlled substances awareness that meets the standards established in the Board of Pharmacy Controlled Substances Administrative Rules, R 338.3135 prior to being issued a license.
Criminal Background Check – Once the online application is completed and submitted you will be emailed an Application Confirmation letter containing instructions to complete the Criminal Background Check (except those applicants seeking relicensure, for a license that expired within the last three years).
Good Moral Character Questions – Documentation and explanation will be required if you answer “yes” to either question to show at the current time you have the ability to, and are likely to, serve the public in a fair, honest and open manner, that you are rehabilitated, or that the substance of the former offense is not reasonably related to the occupation or profession for which you are seeking a license
Human Trafficking Training – Beginning April 23, 2021, completion of a one-time training to identify victims of human trafficking is required for an individual seeking licensure that meets the standards of Administrative Rule 338.6103.
Implicit Bias Training– Beginning June 1, 2022, completion of 2 hours of implicit bias training within the 5 years immediately preceding issuance of the license or registration is required. This requirement does not apply to applicants for relicensure.
Social Security Number (SSN)– An individual applying for licensure is required to provide his or her social security number at the time of application. If exempt under law from obtaining an SSN or you do not have an SSN, the SSN affidavit form will be required to be uploaded at the time the application is submitted
Verification of Licensure – Verification of licensure must be sent directly to our office by the licensing agency of any state or province of Canada in which you hold or ever held a license as a physician’s assistant. Verification includes, but is not limited to, showing proof that the applicant’s license is in good standing and, if applicable, the record of any disciplinary action taken or pending against the applicant. Verification can be emailed to [email protected] or mailed to the Bureau of Professional Licensing, PO Box 30670, Lansing, MI 48909.
Professional Education – Name of school attended, and name of educational program completed
English Language Proficiency – An individual applying for licensure must demonstrate a working knowledge of the English language. This can be established if either the applicant’s required health professional educational program was taught in English, a transcript establishes the applicant earned not less than 60 college level credits from an English-speaking graduate or undergraduate school, or that the applicant obtained a passing score on an approved English proficiency exam as established by the department under R 338.7002b(2) of the Public Health Code – General Rules
Official transcripts containing the degree awarded and the date conferred submitted directly to this office from the ARC-PA accredited educational program from which you graduated. Transcripts must be emailed to [email protected] or mailed to the Bureau of Professional Licensing, PO Box 30670, Lansing, MI 48909.
PANCE Scores – Verification of your passing examination scores submitted directly to this office from the National Commission on Certification of Physician Assistants (NCCPA) by email to [email protected] or by mail to the Bureau of Professional Licensing, PO Box 30670, Lansing, MI 48909
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Minnesota.
PHYSICIAN ASSISTANT
Licensure Instructions
Enclosed are the application forms for licensure as a Physician Assistant (PA). Please review all application
materials before submitting your application. The Board of Medical Practice (Board) recommends that you use
current application forms and submit your application and supporting documentation in a timely manner. The
Board reserves the right to reject any outdated application or supporting documentation. You are responsible
for any additional processing fees incurred to supplement your application. Incomplete applications and
supporting documentation will be destroyed after six months of inactivity on the file.
Application
It is your responsibility to ensure submission of all required forms. Primary source verification of the following
must be mailed directly to the Minnesota Board of Medical Practice by the facility or person authorized
to complete the form:
• State board verification. A credential verification form must be submitted by each state in which you
currently hold or have ever held a health care professional license or credential.
• Verification of education. The form must be completed and submitted by your PA education program.
• Current NCCPA certification and examination scores. The most efficient way to request release of
your current NCCPA certification and examination scores is to submit a request online through your
NCCPA login account at www.nccpa.net. Alternatively, you may submit your request in writing to
NCCPA by email ([email protected]), fax (678-417-8135), or US mail (12000 Findley Road, Suite 100,
Johns Creek, GA 30097) with your full name and social security number.
• Recommendations. Recommendation forms must be submitted by two health care professionals with
whom you have worked during the last five years. At least one must be from a physician.
Your completed application must include the following:
• Non-refundable fee of $268.25 (includes $120 application fee, $115.00 annual registration fee, and
$33.25 criminal background check fee). The amount of the annual registration fee will be prorated at the
time of your first license renewal. Make checks payable to the Minnesota Board of Medical Practice.
Applications with absent or incorrect fees will be returned.
• Accounting of all time from high school graduation to the date of application. Include month and year for
all dates listed. During continuous years of education, periods of three months or less (summer break)
need not be accounted for.
• Your name on the application for licensure and NCCPA certification must be the same OR you must
submit a copy of supporting documentation (e.g. marriage license).
• A recent, full-face, 2” X 3” color photograph must be affixed as indicated on the application and notarized
as a true likeness.
• Affidavit of Collaborative Practice form, pursuant to Minnesota Statute § 147A.02(c).
• Any other information requested by the Board.
Your completed application and all written correspondence should be addressed to:
Minnesota Board of Medical Practice – PA Licensure
335 Randolph Avenue, Suite 140
St. Paul, Minnesota 55102
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Mississippi.
MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
CYPRESS RIDGE BUILDING • 1867 CRANE RIDGE DRIVE, SUITE 200-B • JACKSON, MS 39216
(601) 987-3079
WWW.MSBML.MS.GOV
Items submitted by the applicant
Submit the following items upon completion of the online application and fees. All documents received become the property of the Board and will not be returned.
(A) Birth Certificate or Passport. Applicant shall submit a certified copy or notarized copy (see notary guide and notary form) of original birth certificate or other certification. In the event the name of the applicant differs from the name reflected on the applicant’s birth certificate or other certification, the applicant shall submit evidence satisfactory to the Board that establishes the true identity of the applicant (legal name change, marriage certificate, divorce decree, etcetera).
(B) Physician Assistant School Diploma. Applicant shall submit a copy of the original medical school diploma. Document should be uploaded via the Licensure Gateway. If the applicant’s diploma does not indicate that he/she graduated from a Physician Assistant studies program, the applicant is required to have the school submit an official transcript to the Board as primary source verification.
(C) Driver’s License. Applicant shall submit a copy of current driver’s license. Document should be uploaded via the Licensure Gateway.
(D) Translated Foreign Language Documents. Any document required to be submitted to the Board by the applicant which is not in the English language must be accompanied by a certified translation thereof into English by a recognized translator. The Board will accept a notarized copy (see notary guide and notary form) of certified translation. Physician Assistant schools may submit original and translated diplomas on behalf of an application.
(E) Affidavit and Perpetual Release Form. Applicant shall carefully read the oath of the truthfulness of information supplied in this form which gives consent to release information to and from the Board. Applicant must sign and notarize (see notary guide) this form. A copy of this form must be included with each hospital privilege form sent to a hospital. The ORIGINAL “Affidavit and Perpetual Release of Information” form must be mailed to the Board.
(F) Photograph. Applicant must attach a photograph taken within the last sixty (60) days to the date of the Affidavit and Perpetual Release of Information form. This should be a wallet-sized, passport-type photograph attached to the Affidavit and Perpetual Release of Information form. Informal snapshots will not be accepted. (See Photograph Guidelines)
MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
CYPRESS RIDGE BUILDING • 1867 CRANE RIDGE DRIVE, SUITE 200-B • JACKSON, MS 39216
(601) 987-3079
WWW.MSBML.MS.GOV
(G) Electronic Photograph. Applicant must also provide an electronic, passport-type photograph taken within the last sixty (60) days. Photo must be uploaded via the Licensure Gateway. (See Photograph Guidelines)
(H) Applicant Fingerprints. Applicant may submit fingerprints via three ways:
a. Two Standard FD-258 fingerprint cards will be mailed to the address the applicant supplies when the application is submitted. The applicant may have the cards completed at their local law enforcement agency, or other fingerprinting service provider for processing and return them to the Board.
b. Some law enforcement agencies and other fingerprinting service providers will provide the Standard FD-258 fingerprint cards. Once completed, the applicant should submit the completed cards to the Board.
c. LiveScan prints can be completed at MSBML. If an applicant selects this option, he or she will be contacted by the Board, once the application has been reviewed and approved by the Board for licensure, to schedule a LiveScan fingerprinting appointment.
Verifications to be requested by the applicant
Primary source verifications are required. Verifications will only be accepted if sent directly from the institution to the Board. Do not have the institutions send verifications back to the applicant or other third party. Board policy requires original documents from primary source. Verifications may be returned to the Board via email or mail. Email is preferable.
(A) Appendix A. Applicant shall send this form to each Physician Assistant attended and request the Physician Assistant school to forward the completed form to the Board.
(B) Appendix B. Applicant must account for all time since graduation from Physician Assistant school. All activities following Physician Assistant school must be accounted for. Each activity for the past five (5) years must be verified by the institution. Applicant shall send this form to the institution where activities were performed. The Board may, at its’ discretion, request additional verification of activities beyond the 5 years. Activities which occurred outside of the U.S. or Canada does not require verification.
(C) Appendix C. Applicant shall request verification of hospital or staffing privileges he/she currently holds or previously held within the past five (5) years to be submitted directly to the Board. The Board may, at its’ discretion, request additional verification of hospital or staffing privileges beyond the 5 years.
MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
CYPRESS RIDGE BUILDING • 1867 CRANE RIDGE DRIVE, SUITE 200-B • JACKSON, MS 39216
(601) 987-3079
(D) Appendix D. Applicant must contact each state in which he/she holds or has held a license to practice medicine to determine the best method of having licensure verification submitted to the Board. This includes active and inactive licenses. Appendix D may be used for states requiring written requests. The Board also accepts licensure certifications processed through VeriDoc at : https://www.veridoc.org/index.aspx.
(E) Examination Report. The applicant must request an examination report from the National Commission on Certification of Physician Assistants (NCCPA) to be sent to the Board at: https://www.nccpa.net/
(F) Military Records. If the applicant served in any branch of the military (during or after Physician Assistant school), the applicant must request a DD-214 Form or its equivalent to be sent to the Board. The Board will accept a notarized copy of the DD-214 Form from the applicant (see notary guide and notary form). If the applicant is active duty military, applicant must request a letter of standing to be submitted by his or her commanding officer to the Board via email or mail.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Missouri.
PA Licensure
· Verification of Licensure Form
· Certificate of Professional Education
· Application;
· Collaborative Practice Arrangement
· Letter of Reference
· Armed Forces of the United States Form.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Montana.
IMPORTANT: A Physician Assistant may not practice medicine in Montana in any manner without
the following (both are required):
1) an active Montana license.
2) a signed Supervision Agreement on file with the Board.
LICENSING REQUIREMENTS:
Must be a graduate of a physician assistant training program accredited by the Accreditation Review
Commission on Education for the Physician Assistant (ARC-PA) or, if accreditation was granted before
2001, accredited by the American Medical Association's Committee on Allied Health Education and
Accreditation or the Commission on Accreditation of Allied Health Education Programs.
Must have successfully passed an examination administered by the National Commission on
Certification of Physician Assistants.
Must be of good moral character.
FEES: License Application Fee
$ 25.00 Supervision Agreement Application Fee
Make payable to: Montana Board of Medical Examiners
(Fees are Non-refundable)
DOCUMENTS: The following documentation must be submitted to the Board office in
order to complete your license application.
Original State Licensing Verifications (Form enclosed)
This form must be sent to all state boards or agencies in which you hold or ever held
any license to practice in any profession. The completed verification, with original
signature and seal, must be returned directly to the Montana State Board of Medical
Examiners directly from that licensing agency.
NOTE: Any Documents not in English must be accompanied by certified translations.
NEW! The Board no longer requires P.A. applicants to submit a National Practitioner Data
Bank (NPDB) self-query or a DEA Query. Instead, the Board will request a report from
the NPDB about each applicant and obtain DEA information directly.
For more information about the NPDB and its reports, visit www.npdb
APPLICATION PROCEDURES:
When the application is complete, it will be processed and considered by Board
staff for licensure.
If the application is considered non-routine there may be a delay in the processing of the
application. The applicant may be notified to submit additional information or may
be required to appear before the Board for a personal interview for consideration of
the application during a regularly scheduled Board meeting.
For an application requiring review by the full Board, all materials must be
received by the Board office no later than 15 working days prior to the
Board’s next scheduled meeting. Applications completed after that deadline
will not be put on the Board’s agenda. The Board meets six times per year
(generally the third Friday of odd-numbered months) beginning in January. Please
visit www.medicalboard.mt.gov for exact meeting dates.
PA app5 Revised
01/2020
Page 2 of 13
All verifications of licensure must be sent directly to the Board office from each state licensing
board in which the applicant is currently licensed or has ever held a license. Please make
copies of the attached verification request form as needed. Some states charge a fee for
verifications. Contact each state board prior to sending the request to get specific information
about requesting license verification.
Keep the Board office informed at all times of any address changes or changes in license
status, complaints or proposed disciplinary action. This is essential for timely processing of
your application and subsequent licensure.
PROCESSING PROCEDURES:
Once a completed routine application is received it may take up to 30 days to process.
The applicant will be notified in writing of any deficient or missing items from the
application file.
The Board of Medical Examiners will request a report from the National Practitioner
DataBank (NPDB.) You do not have to submit a “self-query” to the NPDB. You will be
notified if the Board requires any additional information as a result of receiving the
NPDB report.
SUPERVISION AGREEMENT:
A physician assistant has a dependent practice and must be under physician supervision. Under
37-20-101 and 37-20-403, MCA, the supervising physician is professionally and legally
responsible for the all care and treatment of the physician assistant's patients.
In accordance with 37-20-401(5), MCA, a “supervision agreement” means a written agreement
between a supervising physician and a physician assistant providing for the supervision of the
physician assistant.
In accordance with Board rules, “supervision” is defined as accepting responsibility for, and
overseeing all care and treatment of the physician assistant by telephone, radio or in person as
frequently as necessary considering the location, nature of practice and experience of the physician
assistant.
SUPERVISION RELATIONSHIP EDUCATION:
A supervision physician or physician assistant who is new to supervision relationships in
Montana will also be required to submit a certificate of completion for the board-approved
online education for physicians and physician assistants in supervision relationships. One
can access the education and assessment here: https://dlitraining.mt.gov/login/index.php
You will find instructions for setting up/logging into the course on the board website, here.
Upon passage of the quiz please submit the certificate of completion in one of the
following ways:
email to [email protected]
mail to Board of Medical Examiners, PO Box 200513, Helena, MT 59620-0513
Øupload to your online application
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Nebraska.
APPLICATION PROCESS - To apply for a License:
NON-ENGLISH DOCUMENTS. Any documents written in a language other than English must translated into the English language. You must submit a copy of the original document and the translated document. The translation must be an original document and contain the notarized or equivalent signature of the translator. An individual may not translate his/her own documents.
1)US Citizenship/Lawful Presence (must be at least 19 years old):
U.S. Citizen, a PHOTOCOPY of one of the following:
Birth Certificate (Hospital issued keepsake birth certificates cannot be accepted).
U.S. Passport (unexpired or expired).
Certificate of Naturalization.
Other documents that show U.S. Citizenship.
A Driver’s License is NOT acceptable.
NOT a U.S. Citizen, a PHOTOCOPY of one of the following:
Green Card, otherwise known as a Permanent Resident Card (Form I-551), both front and back of the card;
Form I-94 (Arrival-Departure Record) AND an unexpired foreign passport with a valid unexpired US visa; or
Employment Authorization Card AND
An approved deferred action status (DACA);
A pending application for asylum in the United States;
A pending or approved application for temporary protected status in the United States; or
A pending application for adjustment of status to that of an alien lawfully admitted for permanent
Residence in the United States or conditional permanent resident status in the United States.
NOTE: Documents (other than those for U.S. Citizenship) are verified by our office through the Department of Homeland Security. This process may take up to 30 days. STEP 1: Get copies of the following documents:
Physician Assistant Application - License Information - Page 2
2) Education and Transcript: You must have your medical school or electronic transcript service submit an official college or university transcript directly to our office. If sending by e-mail, send to [email protected]
Information Relating to Military Education, Training, or Service: If you have completed education, training, or service that you believe is substantially similar to the education or training required for this credential while you were a member of the armed forces of the United States, active or reserve, the National Guard of any state, the military reserves of any state, or the naval militia of any state, you may submit such evidence with your application for review.
3) Examination: Official Score Reports sent directly to our office from NCCPA.
4) Medical Malpractice Information: If you answered YES: Indicate the total number of claims you have had which resulted in (A) an adverse judgment against you; (B) a settlement made on your behalf, including those made prior to suite in which the patient released any professional liability claim against you; (C) an award was required or made by you or on your behalf.
Submit a detailed explanation of each claim to include the following:
· Name, sex and age of patient;
· Date of occurrence;
· Initial event (procedure/diagnosis);
· Subsequent event that precipitated the claims – include the time sequence in relation to the initial event;
· Damages – a description of damages or alleged damages resulting from the initial and subsequent events;
· Date of filing of malpractice claim in court (if applicable);
· Outcome of claim – include the court disposition, whether or not the case was settled, and the amount of any monetary settlement or judgment made on your behalf;
· Date of final outcome of claim.
If You Answered YES To pending claims: Indicate the total number of malpractice claims that are currently pending against you. Submit the following for each pending claim: (A) A detailed explanation of the claim to include the information as outlined above; (B) Copies of the court documents that outline the statement of charges (often called the “Complaint”); (C) Letter from the attorney stating the current status of the claim.
5) Other State License Information: If you hold or have held a health related license in any state (other than Nebraska) you must contact that state and request a certification/verification of your license (do not send a copy of your license).
6) Criminal Background Check: A criminal background check is required for all applicants for an individual license in medicine and surgery or osteopathic medicine and surgery. Standard processing time for background checks can take up to 8-10 weeks. Background checks will NOT be expedited for any reason.
7) Conviction Information: If you have EVER received a ticket from law enforcement or animal control, check the court system to see if the ticket is on your record as a misdemeanor or felony conviction. Speeding tickets are not misdemeanors or felonies. You are required to list ALL convictions (regardless of when they occurred) on the application; you are NOT required to list infractions, diversions or dismissals. Misdemeanor and felony convictions can either be processed through traffic or criminal court, so when you check with the county court/district court, you should ask for both traffic and criminal court misdemeanor/felony convictions.
If you have convictions, you must submit:
(i) A copy of the court record related to all misdemeanor and felony convictions, that includes the statement of charges and final disposition, if the conviction(s) occurred in a state other than Nebraska;
(ii) An explanation of the events leading to the conviction (what, when, where, why) and a summary of actions that the applicant has taken to address the behaviors or actions related to the conviction; and
(iii) A letter from the applicant’s probation officer addressing the terms and current status of the probation, if the applicant is currently on probation.
If you had an alcohol and drug evaluation and/or completed treatment, to assist the Board and Department in review of any drug and/or alcohol conviction(s), we encourage you to request that the treatment provider submit all evaluations and discharge summaries directly to the Department.
The following provides SOME examples of convictions; this is NOT a complete list
· MIP/ Tobacco Use by Minor
· DUI / DWI / Open Container
· Controlled Substance
· Shoplifting / Theft / Burglary
· Unauthorized use of a Financial Transaction
· Disturbing the Peace
· Assault / Prostitution
· Disorderly Conduct / Disorderly House
· Fail to Appear in Court
· Driving under Suspension / Revocation
· License Vehicle without Liability Insurance
· False Information or Reporting
· Reckless Driving / Leave the Scene of an Accident
· Operator not Carrying License
· Unlawful Display of Plates/Renewal tabs
· Park Rule Violation / Curfew Violation
· Dog at Large / Fail to Vaccinate Animal
· Littering / Fireworks / Bad Check
NOTE: If you have any criminal charges or license disciplinary actions pending that result in a conviction or license discipline, you are required to report such action to the Investigative Unit within 30 days of the conviction or disciplinary action. Reporting forms can be obtained at the following website: https://dhhs.ne.gov/Pages/Investigations.aspx or by phone 402-471-0175.
8) Active Federal DEA Certificate: A photocopy of your DEA Registration Card needs to be submitted if controlled substances will be prescribed, administered or dispenses by the licensee. This is not required for licensure. https://www.deadiversion.usdoj.gov/
Temporary License: If you apply for a temporary license, you must submit the temporary application, the license application and
pay both fees (unless you qualified for a fee waiver).
Contact Information: Licensure Unit, Phone: 402-471-2118 / FAX: 402-742-8355 / E-Mail: [email protected]
STEP 2: Complete all pages and questions on the Application
STEP 3: Submit your application to the Licensure Unit £ Completed Application £ Citizenship or Lawful Presence Document £ Education Documents £ Conviction Records (if you have convictions) £ License Certifications (if licensed in another state) (if requested) £ The License Fee (unless you qualified for a fee waiver). See the license application for a listing of fees for Medicine. Pay by check/money order; debit or credit card is not accepted.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Nevada.
Physician Assistant Licensure
Attention Applicant
Pursuant to NRS 630.167, as part of the application process, you are required to submit to a criminal background investigation. Upon receipt of your completed application, your License Specialist will send you an authorization form, the appropriate fingerprint cards, and instructions.
Forms
Physician Assistant Application for Licensure
Use this link to apply online for licensure as a Physician Assistant in the state of Nevada.
Form 1 - Physician Assistant Application
Education Verification
Form 2 - Physician Assistant Application
NCCPA Certification
Form 3 - Physician Assistant Application
Verification of State Licensure
Form 4 - Physician Assistant Application
Malpractice Claim Verification
Form A - Physician Assistant Application
Release
Form B - Physician Assistant Application
List of Malpractice Insurance Carriers
Civil Applicant Waiver - Physician Assistant Application
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in New Hampshire.
TO THE APPLICANT:
This application must be completed in full for consideration of certification as a Physician Assistant in the state of New Hampshire. The following documentation is required:
1. Completion of the enclosed supervisory form with original signatures from the designating Registered
Supervisory Physician/Alternate Registered Supervisory Physician.
*2. Certified proof of graduation from Physician Assistant Program as defined in Med 601.03.
*3. Certification of scores received directly from National Commission on Certification of Physician Assistants (NCCPA).
4. Copy of the applicant’s curriculum vitae or resume.
5. Two letters of reference from physicians who can attest to your performance as a Physician Assistant. These
letters must be on proper letterhead, submitted as originals. References may be submitted by the applicant or
by the physician providing the reference.
6. State Clearance (form attached) from every state in which you have ever held a license.
*2 and 3 above may be obtained through the Federation of State Medical Boards’ Credentialing Verification Service (FCVS). NOTE: FCVS IS NOT REQUIRED FOR LICENSURE IN NEW HAMPSHIRE. FCVS provides primary source verification of your “core” medical credentials. The base fee for the FCVS profile is $145.00. The application for FCVS is available via the Federation’s website at www.fsmb.org or you may contact FCVS at 1-800-ASK-FCVS.
**You will receive an acknowledgment letter once your application has been received. This letter will advise you of what information, if any, is outstanding at that time. If you do not receive an acknowledgment letter within 30 days, please contact the Board between 8:00 A.M. and 4:00 P.M. EST. With the acknowledgement letter, you will receive paperwork to complete a criminal background check. Pursuant to RSA 328-D:3-a, you are required to submit a notarized criminal history record release form, along with a fee, which authorizes the release of your criminal history record, if any, to the Board. This form will be provided to you with your acknowledgment letter once your application has been received by the Board.
A copy of the PA Practice Act (RSA 328-D) and the Administrative Rules are enclosed for your information and file.
Any change in RSP/ARSP after licensure will require filing of a change in supervisor form, obtained through this office.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in New Jersey.
Physician Assistant Advisory Committee
Applications and Forms
PLEASE READ: Paper Applications will no longer be accepted after Friday, June 18, 2021. If you have submitted a paper application prior to this date, it will be processed. Any applications received after this date, will be returned and you will be redirected to complete an application online. |
Applications
- Physician Assistant Application for Licensure (online application)
- Control Dangerous Substances Application Dispenser-Prescriber (Mid-Level Practitioner )
Forms
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in New Mexico.
INSTRUCTIONS FOR COMPLETING THE PHYSICIAN ASSISTANT APPLICATION
Procedures
Complete the application in its entirety as neatly and legibly as possible. Please type or print in black or blue ink.
1. Board Application
You must complete all components of the application. If a component does not apply to you, please mark it as non-applicable.
2. Physician Assistant Medical Education Certification
You must have your Physician Assistant Program verify your degree. The completed verification, including the program’s seal, must be sent directly to the Board office from the Physician Assistant Program.
3. NCCPA Certification
Please provide your NCCPA Number on the application. Board staff will verify NCCPA Certification.
4. Verification of Licensure / Registration
You must have each state licensing authority that has ever issued you a Physician Assistant license or any other health related license/registration verify the standing of that license/registration directly to the Board. You may use the enclosed form entitled “Verification of Licensure/Registration.” Make photocopies as required. Complete the release on the top half of the form and send one copy to each jurisdiction, or you may contact each licensing Board to inquire what they require to have your license verified for the New Mexico Medical Board. The verifications must be sent directly to the Board office from the licensing Board.
5. Professional Recommendations
You must have two (2) Professional Recommendation forms completed and sent directly to the Board by physicians or physician assistants licensed to practice medicine in the United States or Physician Assistant Program Directors, or the Director’s designee who have personal knowledge of the applicant’s moral character and competence to practice.
6. Work Experience Verification for Supervised PA
You must have the chief of staff or facility’s administrative staff in each and every hospital or health facility where you have held privileges or been employed during the past two (2) years complete the Work Experience Verification form(s) and return the completed form(s) directly to the New Mexico Medical Board.
7. Verification of Clinical Practice for Collaborative PA
You must have at least one of your supervising physicians complete the Work Experience Verification form(s) to verify clinical practice as a physician assistant for three years immediately preceding the application and return the completed form(s) directly to the New Mexico Medical Board.
8. Verification of Current Malpractice Liability Insurance for Collaborative PA
You must provide the Board with a copy of your certificate of current malpractice liability insurance.
9. Applicants Oath
You must complete the form entitled “Applicant’s Oath” in its entirety including affixing a recent (less than 6 months) color passport quality photograph of yourself in the designated space.
10.Supervising Physician Statement of Responsibility (SPSR)
Upon employment and before beginning practice, a supervised physician assistant together with a New Mexico licensed physician (MD), must submit a completed “Supervising Physician Statement of Responsibility Form” directly to the Board office. A supervised Physician Assistant may not begin practice until a completed and signed Supervising Physician Statement of Responsibility (SPSR) form is received by the New Mexico Medical Board. However, a license may be issued prior to the Board receiving the completed SPSR form.
11.Submitting the Board Application
Attach your payment to the front of the application. Make payment in U.S. funds to the New Mexico Medical Board. Mail your application, appropriate fee, Applicant’s Oath and any other supporting documents to:
New Mexico Medical Board
2055 S. Pacheco Street
Building 400
Santa Fe, New Mexico 87505
11.Personal Interview
If you are required to schedule an appointment for a personal interview with the Board or the Board’s designee, you will be notified after your application and all required documents have been received and are complete in every detail.
12.License
The initial license is valid until March 1 of the year following expiration of NCCPA Certification.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in New York.
License Requirements
Physician Assistant
General Requirements | Fees | Partial Refunds | Education Requirements | Examination Requirements | Applicants Licensed in Another State | Limited Permits
General Requirements
Any use of the title "physician assistant" within New York State requires licensure.
To be licensed as a physician assistant in New York State you must:
- be of good moral character;
- be at least 21 years of age;
- meet education requirements; and
- meet examination requirements.
You must submit an application for licensure and the other forms indicated, along with the appropriate fee, to the Office of the Professions at the address specified on each form. It is your responsibility to follow up with anyone you have asked to send us material.
The specific requirements for licensure are contained in Title 8, Article 131-B, Section 6541 of New York's Education Law and Part 60 of the Commissioner's Regulations.
You should also read the general licensing information applicable for all professions.
Fees
The fee for licensure is $115 ($70 Application Fee, $45 First Three-Year Registration Fee).
The fee for a limited permit is $105 (the limited permit fee is not refundable).
Fees are subject to change. The fee due is the one in law when your application is received (unless fees are increased retroactively). You will be billed for the difference if fees have been increased.
- Do not send cash.
- If you apply for licensure electronically using the online Application for Licensure, you will be required to pay by credit card.
- Other payments must be made by personal check or money order payable to the New York State Education Department. Your cancelled check is your receipt.
- Mail any required forms and fees to the indicated address on the form.
Please Note: Payment submitted from outside the United States should be made by check or draft on a United States bank and in United States currency; payments submitted in any other form will not be accepted and will be returned.
Partial Refunds
Individuals who withdraw their licensure application may be entitled to a partial refund.
- For the procedure to withdraw your application, contact the RPA Unit at [email protected] or by calling 518-474-3817 ext. 260 or by fax at 518-402-2323.
- The State Education Department is not responsible for any fees paid to an outside testing or credentials verification agency.
If you withdraw your application, obtain a refund, and then decide to seek New York State licensure at a later date, you will be considered a new applicant, and you will be required to pay the licensure fee and meet the licensure requirements in place at the time you reapply.
Education Requirements
To meet the professional education requirement for licensure as a physician assistant, you must have completed high school or its equivalent and you must present satisfactory evidence of completion of a program for the training of physician assistants that is approved by the New York State Education Department as licensure qualifying or accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or a program that is determined by the Department to be the substantial equivalent of a licensure qualifying or accredited program.
For a program for the training of physician assistants to be determined substantially equivalent to a licensure qualifying or accredited program, it must include:
- at least 32 semester hours of classroom work; and
- 40 weeks (1,600 clock hours) of supervised clinical training.
Please note: Graduates of medical programs cannot be licensed as physician assistants based solely on medical education. All applicants for registered physician assistant licensure must fulfill the educational requirements outlined above.
Infection Control and Barrier Precautions:
Every practicing physician assistant must complete approved coursework or training appropriate to the professional's practice in infection control and barrier precautions, including engineering and work practice controls, to prevent the transmission of the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) in the course of professional practice. See additional information and a list of approved providers for this training.
Examination Requirements
You must pass the Physician Assistant National Certifying Examination (PANCE), a computer examination, that is administered by the National Commission on Certification of Physician Assistants (NCCPA).
For more information regarding the examination, including sample questions, costs, dates, application forms, or to have scores transferred to the New York State Education Department, you may call NCCPA at 678-417-8100, visit their Web site at www.nccpa.net or write to:
National Commission on Certification of Physician Assistants
12000 Findley Road
Suite 200
Duluth, GA 30097-1409.
Reasonable Testing Accommodations
For specific information about reasonable testing accommodations for the PANCE exam, contact NCCPA as described above.
Applicants Licensed in Another State
If you are or have been licensed/certified in another jurisdiction(s), you must request the licensing authority of the jurisdiction(s) to provide verification of your licensure/certification on Form 3 - Verification of Licensure/Certification in Another Jurisdiction. You must meet all requirements for licensure in New York State.
Limited Permit
A limited permit allows an individual who has satisfied all requirements for licensure as a physician assistant except the examination requirement to practice as a physician assistant under appropriate supervision while meeting the requirement. Appropriate supervision is the direct supervision of a currently registered New York State licensed physician.
A limited permit is valid for one year or until notification by the New York State Education Department of denial of your application for licensure. Your permit may be extended for one year. To request an extension of your limited permit you must submit a new Application For Limited Permit (Form 5) and a fee of $105. You may apply for a limited permit by submitting Form 5 and fee of $105 at the same time or anytime after you submit your Application for Licensure (Form 1), licensure fee of $115, and evidence of satisfactory educationColorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in North Carolina.
Application for Full PA License Not Using FCVS - Checklist P a g e | 1
APPLICATION FOR A FULL PHYSICIAN ASSISTANT LICENSE NOT USING FCVS CHECKLIST
The following checklist is designed to assist applicants in submitting the necessary materials needed during the
application process. Delays often occur when applicants fail to provide required information to the Board. The
Licensing section encourages use of provided checklists for all license types.
Status
Item
Notes
Online Application
Complete the chronological information in month / year format beginning with high school and answer all questions. Documentation can be uploaded to your application via the gateway for any affirmative responses provided.
Applicant Oath
Document will need to be signed and notarized. The original must be sent to the NCMB. Faxes and emailed copies will not be accepted.
Legal Resident Status
U.S. citizens must submit a photocopy of one of the following: 1) Birth certificate 2) Valid, unexpired U.S. passport
Not a U.S. citizen? Provide a photocopy of one of the following:
1) Alien Registration Card or Green Card (form I-555)
2) Employment Authorization Document (form I-688 B or I-766)
3) Certification of Report of Birth (form DS-1350)
4) Arrival/Departure Record (form I-94)
5) Other documentation providing lawful U.S. status
Documentation can be uploaded to your application via the gateway.
Name Change Documentation (if applicable)
A photocopy of documentation of a legal name change (marriage certificate, divorce decree, etc). Documentation can be uploaded to your application via the gateway.
Verification of PA Education
Form should be sent to your PA program for completion. Your PA program should email the form to [email protected].
NCCPA Examination Scores
Request NCCPA scores documenting current certification be sent to the NCMB. The scores can be emailed directly from the NCCPA to the NCMB at [email protected].
If you are not currently certified by NCCPA and two years or more have passed since graduation from a Physician Assistant Education Program, provide documentation of at least 100 hours of continuing medical education (CME) during the preceding two years, at least 50 hours of which must be recognized by the NCCPA as Category I CME. Documentation can be sent to [email protected].
PA Reference Forms
Two original reference forms are required. One form must be completed by a physician, and the other reference form must be from a physician assistant peer whom you have worked or trained with. Reference forms can be emailed to [email protected] from the author.
Fingerprint Cards, Authority for Release of Information Form, and Criminal History
Applicants outside North Carolina
You will need to go to your local law enforcement office to be fingerprinted. Your fingerprints will need to be provided on a FD-258 fingerprint card which can be provided by the law enforcement office. 2 fingerprint cards will need to be submitted.
You will need to upload the Authority for Release of Information form to you application via the gateway.
Applicants in North Carolina
Live Scan is available to those applicants who are in NC. You will need to go to your local law enforcement office to have this process completed and take the following with you: (1) Applicant Information form, and (2) Electronic Fingerprint Submission Release of Information form.
Once the fingerprinting process has been completed, you will need to upload the Electronic Fingerprint Submission Release of Information form to your application via the gateway.
The Applicant Information form can be discarded after being fingerprinted.
Interview
You will be notified if a personal interview will be required.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in North Dakota.
New Applicants
To become eligible to practice as a physician assistant in North Dakota, the PA:
- Must provide evidence of completing/graduating from a physician assistant program;
- Must have passed the certifying examination of the National Commission on Certification of Physician Assistants, and;
- Must provide evidence of current "good standing" with the National Commission on Certification of Physician Assistants (NCCPA).
Instructions
- Complete every section of the online application.
- $55.00 application fee payable by credit card.
- Documents needing to be uploaded or mailed to the North Dakota Board of Medicine:
-
- A photocopy of your diploma from your PA program.
- A photocopy of your NCCPA wall certificate.
- A recent 2"x3" unmounted photo of yourself. If you choose to submit a paper photograph please follow these instructions:
The photo must be:- Original passport quality photograph. No computer scanned or polaroid photograph with thick backing.
- Close-up front view of head and shoulders no larger than 2" X 3" and no smaller than 2" X 2".
- Must have been taken within 90-120 days prior of submitting this application.
- You must complete and submit the Criminal History Record Check Requestform and two fingerprint cards along with a money order of $41.25 made payable to the Office of the Attorney General. Mail completed fingerprint cards along with the money order to the North Dakota Board of Medicine: 4204 Boulder Ridge Rd; Suite 260, Bismarck, ND 58503. You should call your local law enforcement office for times and locations that fingerprinting services are available. Be sure to bring a photo ID. A small fee may be required.
DO NOT BEND OR FOLD the fingerprint cards when mailing them to us as they will be rejected and you will be required to be fingerprinted again. Be sure all personal information is completed on the cards. Click here for instructions and example. - You must direct the licensing board of each state/province where you have ever applied for any type of physician assistant license (regardless of whether the license was granted or not granted, is active or inactive, temporary or permanent, restricted or unrestricted) to provide the North Dakota Board of Medicine with verification of your licensure status.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Ohio.
Physician Assistant Core Licensure Eligibility Requirements
To be eligible to receive a license to practice as a physician assistant, an applicant must meet all the following requirements:
1. The applicant shall be at least eighteen years of age
2. The applicant shall be of good moral character
3. The applicant shall have the results of a criminal records check (FBI and Ohio BCI) submitted to the Board
4. The applicant shall hold current Certification by the National Commission on Certification of Physician Assistants (NCCPA)
5. The applicant must meet one or more of the routes listed below:
Route 1 - The applicant shall hold a master's or higher degree obtained from a program accredited by the Accreditation Review Commission on Education for the Physician Assistant program (ARC-PA).
Route 2* (see note below) - The applicant shall hold a current, valid license or other form of authority to practice as a physician assistant issued by another jurisdiction and have been in active practice in any jurisdiction throughout the two-year period immediately preceding the date of application.
Route 3* (see note below) - The applicant shall hold a degree obtained from a program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and meet either of the following experience requirements:
(a) Have experience practicing as a physician assistant for at least two consecutive years, immediately preceding the date of application, while on active duty, with evidence of service under honorable conditions, in any of the armed forces of the United States or the national guard of any state, including any experience attained while practicing as a physician assistant at a health care facility or clinic operated by the United States Department of Veterans Affairs.
(b) Have experience practicing as a physician assistant for at least two consecutive years, immediately preceding the date of application, while on active duty in the United States Public Health Service commissioned corps.
State Medical Board of Ohio
30 E. Broad St., 3rd Floor l Columbus, Ohio 43215 l (614) 466-3934
www.med.ohio.gov
Route 4 - The applicant shall hold both of the following degrees:
(a) A degree other than a master’s or higher degree obtained from a program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)
(b) A Master's or higher degree in a course of study with clinical relevance to the practice of physician assistants and obtained from a program accredited by regional or specialized and professional accrediting agency recognized by the Council for Higher Education Accreditation (CHEA).
Route 5* (see note below) - The applicant shall hold a degree obtained as a result of being enrolled on January 1, 2008, in a program in this state that was accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) but did not grant a Master's or higher degree to individuals enrolled in the program on that date, and completing the program on or before December 31, 2009.
*Unless the applicant had prescriptive authority while practicing as a physician assistant in another jurisdiction, in the military, or in the public health service, the license issued to an applicant who qualifies under Route 2, Route 3 and/or Route 5 above does not authorize the holder to exercise physician-delegated prescriptive authority.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Oklahoma.
Qualifications – To be eligible for licensure as a physician assistant (PA) an applicant must meet the following qualifications:
1. Graduation from an accredited physician assistant program recognized by the Oklahoma State Board of Medical Licensure and Supervision (Board); and
2. Passed the Physician Assistant National Certifying Examination administered by the National Commission on Certification of Physician Assistants; and
3. Passed with a score of 75% or greater a jurisprudence examination prepared by the Board.
Reinstatement – An applicant for reinstatement of a PA license shall meet all requirements in effect at the time reinstatement is requested.
Fees – All fees are non-refundable. Fees for application must be paid online by credit card, debit card, or EFT from checking or savings account. Fees returned by the payer’s financial institution must be replaced by a certified check or money order and include a $30 returned check processing fee.
Physician Assistant Application for License Fee
$150
Physician Assistant License Renewal Fee
$125
Application – must be completed online and can be found at https://www.ok.gov/medlic/licensing/app/menu.php.
1. All sections must be completed to the best of your knowledge. No applicant shall be awarded a license who does not provide the Board with complete, open and honest responses to all requests for information. For those items that do not apply to you, mark N/A (Not Applicable).
2. Any “yes” answer in the Attestation section of the application must be explained by a sworn affidavit (a statement signed by the applicant and notarized). Note: You are required to inform the Board if your response to any of the questions changes after you complete the application and submit it for processing.
a. Any “yes” answers to those questions concerning previous or current treatment require written releases by the applicant directly to the treatment provider with copies of such releases to accompany the application. The treatment providers should be instructed to provide their responses directly to this office.
b. If you answer “yes” to the question regarding previous arrests, you must provide all available police reports, arrest records, and court documents.
3. A detailed chronological life history from age eighteen years to the present, including education, training, employment, military service, and non-work time must be provided.
4. List all jurisdictions, United States or foreign, in which applicant is licensed, previously licensed, or has applied for licensure to practice as a physician assistant or is authorized or has applied for authorization to practice as a physician assistant. Applicant must also list all jurisdictions, United States or foreign, in which applicant has been denied authorization to practice or have voluntarily surrendered a license or authorization to practice. Verification of all licenses or certificates ever held in the United States and/or Canada must be verified by the respective Licensing Board.
Forms - all forms can be found at https://www.okmedicalboard.org/physician_assistants#forms-resources
1. Extended Background Check – Applicants for licensure are required to request an Extended Background Check.
OKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION
101 NE 51ST STREET
OKLAHOMA CITY OK 73105
Phone: (405)962-1400 Fax: (405)962-1440 email: [email protected]
PA APPLICATION INSTRUCTIONS
Revised 09/2021 Page 2 of 3
2. Evidence of Status Form - In order to verify citizenship or qualified alien status, applicants for licensure by endorsement or examination or for reinstatement of their license, must submit an Evidence of Status Form and the required supporting documentation with their application. This form must be notarized and mailed to the office.
3. Photo and Oath Form – Applicants for licensure will be required to complete the Photo and Oath Form. This form must be notarized and mailed to the office.
4. FORM 1 – Graduation from an accredited PA Program must be verified by submitting Form #1 (Allied Verification of Education). The completed form must be submitted directly to the Board by the school. An official transcript of grades with degree posted must be submitted in a sealed envelope or electronically directly from the institution.
5. FORM 3 – Verification of all PA licenses, or certificates ever held in the United States and/or Canada must be sent by the respective Licensing Board directly to the Oklahoma Medical Board office. It is recommended the applicant contact the respective Licensing Board to see how they require ordering the verification.
Temporary Letter to Practice – Form 5 Physician Assistant Delegating Practice Agreement
The Secretary of the Board may grant temporary approval of a license to the physician assistant applicant provided all requirements for licensure have been met and verified.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Oregon.
Items to be Sent From You, the Applicant
Most of these items may be sent via e-mail to [email protected], by fax to 971-673-2670, or by postal mail.
Birth Certificate: Provide a copy of official birth certificate or birth record. Hospital birth certificates are not acceptable. Your complete, legal name, including Jr., II, III, initial only, or no middle name, will be shown on your formal license, and all licensees must pursue their profession under their own name as it appears on the license. A copy of your passport, driver's license, etc., does not meet this requirement and cannot be accepted in lieu of the required birth certificate.
Name Change (due to marriage, divorce, adoption, court order): If you have been known by names other than that exactly on your birth certificate, provide a copy of the legal documentation (marriage certificate, divorce decree, adoption papers, or court order).
Naturalization: It is a violation of law to copy a naturalization document. Instead, please complete the naturalization form provided by the Board with the number, date and place of naturalization. This form must be notarized and is available here.
Photograph: Provide a close-up passport quality photograph, front view, head and shoulders (not profile) taken within 90 days preceding the filing of the application.
Diploma: Provide a copy of your diploma showing graduation from a physician assistant training program.
Fingerprints: Applicants must provide fingerprints in order for the Board to conduct a state and federal criminal records check. All fingerprints are processed through the Oregon State Police (OSP) and the Federal Bureau of Investigation (FBI). For more information, visit the Fingerprint Requirements page.
Medical Practice Act Open-Book Examination: The required MPA examination and open-book materials are available here.
The Board may require other documentation or explanatory statements.
Items to be Sent Directly From the Primary Source
Fees charged by any other agencies to provide verification to the Board are your responsibility.
The following items must be:
- Fully completed with dates in month/day/year format.
- Currently dated.
- On letterhead, computer-generated form, or Board-provided form.
- Mailed in an institution envelope. Do NOT provide your own envelope.
- Faxed or e-mailed responses are not accepted.
Education Verification: Send the Verification of Medical Education form to the dean, administrator, or program director of your physician assistant training program. The form must be completed fully, showing dates of attendance, exact date of graduation and a statement about your educational performance. The Board will return all incomplete forms to the physician assistant program. The Board will not accept verification of education if it is received prior to your graduation. An official of the program must sign the form.
Employment Verification(s): Send the Verification of Health Related Employment form to an official at each place of employment where you practiced any health related profession (including non-clinical work) during the last five (5) years. The form must include complete beginning and ending dates of employment and an evaluation of overall performance. Verifications of employment/practice from where you are currently employed or practicing that are dated more than six (6) months prior to the receipt of your application to the Board must be re-submitted with a current verification. Only employment verifications for the past five (5) years are required unless you are advised otherwise by the Board.
License Verification(s): Send the Verification of Licensure form to an official of the board in each state, province, or country where you have ever been licensed in any health related profession, even if you have never practiced there or if your license has lapsed there. This form or a letter must show license number, date issued, grades if applicable, disciplinary actions (past and present), and current status. Do not request a verification of licensure of a temporary license issued for the completion of a training program unless informed otherwise by the Board. You may be able to request verification of some other United States licenses through VeriDoc's online License Verification System.
NCCPA Certification Verification and Exam History Form: Submit the form directly to the NCCPA at the address listed on the form. The NCCPA will provide the Board with written confirmation of your exam history, scores, certificate number and current certification status with the NCCPA. If you have not yet taken the NCCPA examination and you have completed all other requirements for the PA application, you may be eligible for a Limited License, Pending Examination.
Personal History Questions
If you answer "YES" to any personal history question, please furnish details and request source documents as indicated here.
The Board may require other documentation or explanatory statements.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Pennsylvania.
CheckList Name |
Instructions |
Application |
All applications are processed in order of submission. If this application is not completed within six months, updates of certain sections and/or supporting documents will be required. If the application has not been completed within one year from the date it was received, applicants will be required to submit a new application (another application processing fee) and supporting documents, as necessary. |
Application Fee |
NON REFUNDABLE FEE in the amount of $30.00, made payable by credit/debit card. If the application has not been completed within one year from the date it was received, applicants will be required to submit a new application (another application processing fee) and supporting documents, as necessary.
|
Child Abuse CE |
All health-related licensees/certificate holders and funeral directors are considered “mandatory reporters” under section 6311 of the Child Protective Services Law (23 P.S. § 6311). Therefore, all persons applying for issuance of an initial license or certificate from any of the health-related boards (except the State Board of Veterinary Medicine) or from the State Board of Funeral Directors are required to complete, as a condition of licensure, 3 hours of approved training by the Department of Human Services (DHS) on the topic of child abuse recognition and reporting. After you have completed the required course, the approved provider will electronically submit your name, date of attendance, etc. to the Bureau. For that reason, it is imperative that you register for the course using the information provided on your application for licensure/certification. A list of DHS-approved child abuse education providers can be found on the Department of State Website. |
Criminal History Check |
Provide a recent Criminal History Records Check (CHRC) from the state police or other state agency that is the official repository for criminal history record information for every state in which you have lived, worked, or completed professional training/studies for the past ten (10) years. The report(s) must be dated within 90 days of the date the application is submitted. For applicants living, working, or completing training/studies in Pennsylvania, your CHRC request will be automatically submitted to the Pennsylvania State Police upon submission of this application. The PATCH fee will be included at checkout. Your PA CHRC will be sent directly to the Board/Commission. You will be notified if additional action is required. For individuals living, working, or completing training/studies outside of Pennsylvania during the past ten (10) years, in lieu of obtaining individual state background checks, you may elect to provide BOTH a state CHRC from the state in which you currently reside, AND your FBI Identity History Summary Check, available at https://www.fbi.gov/services/cjis/identity-history-summary-checks. Please note: For applicants currently living, working, or completing training/studies in California, Arizona, or Ohio: Due to the laws of these states, the Board is not an eligible recipient of CHRC's or your CHRC will not be issued to you for upload to the Board. Please obtain your Federal Bureau of Investigation (FBI) Identity History Summary Check, available at the link noted above. |
Databank Report |
Provide an official notification of information (Self Query) from the National Practitioner Data Bank. Please refer to the NPDB website for additional information. When you receive the "Response to your Self Query," you will need to upload it to your online application. The report will need to be uploaded, where prompted, in order to submit your application. |
Education Verification |
Complete Section 1 of the Verification of Education and forward to your physician assistant program for completion of Section 2. The school must return the completed verification directly to the Board. The form will be available for download and printing when the application is submitted. |
Exam Results |
Contact the National Commission on Certification of Physician Assistants, Inc. (NCCPA) and arrange for your exam scores to be sent directly to the Board. |
Letter of Good Standing (LOGS) |
Contact the licensing authorities of the states, territories or countries where you hold or have ever held a license, certificate, permit, registration or other authorization to practice a health-related profession (whether active, inactive, expired or current) and request letters of good standing/verification of licensure in that state or jurisdiction. The letter must include the following: license issue and expiration date, license status (current or expired) and disciplinary standing. The letter(s) of good standing must be sent directly to the Board. |
Opioid CE |
Section 9.1(a) of ABC-MAP* requires that all prescribers or dispensers, as defined in Section 3 of ABC-MAP, applying for licensure/approval complete at least 4 hours of Board-approved education consisting of 2 hours in pain management or the identification of addiction and 2 hours in the practices of prescribing or dispensing of opioids. Applicants seeking licensure/approval on or after July 1, 2017, must document, within one year from issuance of the licensure/ approval, that they completed this education either as part of an initial education program, a stand-alone course from a Board-approved course provider, or a continuing education course from an approved continuing education provider. The 4 hours of Board-approved education needs to be completed only once. See the Board’s website for the Opioid Education Forms and additional information. *The Achieving Better Care by Monitoring All Prescriptions Program Act (ABC-MAP) (Act 191 of 2014, as amended) is available on the Legislature’s website at: http://www.legis.state.pa.us/cfdocs/Legis/LI/uconsCheck. cfm?txtType=HTM&yr=2014&sessInd=0&smthLwInd=0 &act=191. The Board’s Regulations are available on the Board’s website. |
Resume Curriculum Vitae |
You will need to upload, where prompted, a current Curriculum Vitae listing all periods of employment or unemployment (i.e., child rearing, research, etc.) from graduation from the physician assistant program to present. The list must be in chronological order, include the month and year, and indicate the state/territory in which the employment occurred. If you are a new graduate with no employment, you will need to provide a statement to this effect. The resume/curriculum vitae will need to be uploaded, in order to submit your application. |
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Rhode Island.
Completed Application with Cover Page - Applications are valid for 1 year from the day they are received at RIDOH. If you are not licensed within the year you must submit a new application.
Check or money order (preferred), made payable (in U.S. funds only) to the RI General Treasurer in the amount of $110.00 and attached to the upper left-hand corner of the first (Top) page of the application. THIS APPLICATION FEE IS NONREFUNDABLE. Please be advised that this is an application fee and includes the first license only up until the next expiration date. All licenses expire biennally on June 30th of the even numbered years.
Official transcript from an accredited School of Physician Assistants submitted by the college/school/university, directly to the Board. Transcript must include date of completion, graduation date and degree OR Verified Credentials by the Federation of Credentials Verification Service (FCVS) through the Federation of State Medical Boards (FSMB). (FCVS Telephone 1-888-275-3287 or website at http://www.fsmb.org/fcvs
Score/Certification sent directly from the National Commission on Certification of Physician Assistants (NCCPA)OR Verified Credentials by the Federation of Credentials Verification Service (FCVS) through the Federation of State Medical Boards (FSMB). (FCVS Telephone 1-888-275-3287 or website at http://www.fsmb.org/fcvs
Submit a “self-query” of the National Practitioner Data Bank (NPDB). The application is a Practitioner Request
for Information Disclosure, which can be obtained by calling the NPDB, or downloading it from the NPDB web site. You must mail this completed form directly to NPDB. When you receive a response, send the Department the ORIGINAL, UNOPENED response. The Board must have this response in order to complete your application so you are encouraged to make this request as soon as possible. (FCVS Telephone 1-888-767-6732 or website at http://www.npdb-hipdb.com
If you have ever been licensed in another state, license verification(s) must be sent directly from the state(s) in which you hold or have held a license. (Interstate Verification Form included in this application can be used for that purpose)
If applying for expedited military status you must include one of the following: Leave Earning Statement (LES), Letter from Command, Copy of Orders or DD-214 showing honorable discharge.
Rhode Island Controlled Substance Registration (CSR)
Completed Rhode Island Uniform Controlled Substances Act Registration Form (CSR) enclosed in this application to be used for that purpose.
Check or money order (preferred), made payable (in U.S. funds only) to the RI General Treasurer in the amount of $200.00
In order to dispense, prescribe, store, or order controlled substances, you must obtain a Rhode Island Controlled Substance Registration (CSR) and a Drug Enforcement Administration (DEA) Registration.
After you obtain your Rhode Island CSR you must apply for a federal DEA Number. That DEA number must be registered to a RI Business Address. An application for the federal DEA Number can be obtained by contacting DEA: DEA Phone Number (617) 557-2200. Web Site: http://www.deadiversion.usdoj.gov/drugreg/reg_apps/
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in South Carolina.
If you are a new user, create a user account and log into: https://eservice.llr.sc.gov/NewAppsV3/
To submit a completed application you will need to pay the $120 non-refundable application fee. (DO NOT MAIL
A CHECK IN WITH DOCUMENTS.)
You will have the opportunity to upload your required documentation at the end of the online application. This includes:
- Notarized Signature Affidavit with a 2”x2” professional photo (Passport Photo)
- Legal documentation for name change, if applicable
- Copy of your valid Driver’s License, State Issued ID, Passport or Military ID
- Copy of your social security card
- Copy of your current NCCPA Certificate: Visit www.nccpa.net to obtain “verify certificate” page.
- Malpractice Claim Information Form, if applicable
- Legal documentation for name change, if applicable
Have submitted directly to the Board office address above from the issuing agent:
- Certification of Education Form or Official Transcripts
- License Verification from each state medical board that you are currently or have ever been licensed in.
- Criminal Background Check (CBC): Board will forward instructions once application is received.
LICENSURE REQUIREMENTS
Section 40-47-945 (A) Except as otherwise provided in this article, an individual shall obtain a permanent license
from the board before the individual may practice as a physician assistant. The board shall grant a permanent
license as a physician assistant to an applicant who has:
(1) submitted a completed application on forms provided by the Board;
(2) paid the non-refundable application fee;
(3) successful completion of an educational program for physician assistants approved by the Accreditation
Review Commission on Education for the Physician Assistant or its predecessor or successor
organization;
(4) successful completion of the NCCPA certifying examination and provide documentation that he or she
possesses a current, active, NCCPA Certificate;
(5) certified that the applicant is mentally and physically able to engage safely in practice as a physician
assistant;
Application for License to Practice as a PA Electronic Instructions (10/19) Page 2 of 2
(6) no licensure, certificate, or registration as a physician assistant under current discipline, revocation,
suspension, probation, or investigation for cause resulting from the applicant’s practice as a physician
assistant;
(7) good moral character;
(8) submitted to the Board any other information the Board considers necessary to evaluate
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in South Dakota.
The board may grant a license to an applicant who:- Is of good moral character;
- Has successfully completed an educational program for physician assistants accredited by the Accreditation Review Commission on Education for the Physician Assistant or its successor agency, or, prior to 2001, either by the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Program;
- Has passed the Physician Assistant National Certification Examination administered by the National Committee on Education for Physician Assistants; and
- Has submitted verification that the physician assistant applicant is not subject to any disciplinary proceeding or pending complaint before any medical or other licensing board unless the board considers such proceedings or complaint and agrees to licensure
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Tennessee.
Board on Physician Assistants
When completing the application process below, you will be required to submit an official transcript from the institution where you completed your education. The transcript must be mailed directly from the educational institution to the board office located at 665 Mainstream Drive, Nashville, TN 37243.
Applications
►Applying for initial licensure from your professional licensing board has become a bit easier. For the past year, the Department of Health has been working on an online application process that will allow all health care professionals to apply online for an initial license and complete (and update as necessary) a practitioner profile mandatory for certain professions. The process is user friendly and convenient and even allows you to pay for your initial application utilizing a credit card, debit card or e-check. You will also be able to upload many of the documents required to complete your initial application! Please go to the initial application link below to begin the online process.
- Notice of intent to Terminate Supervision
- Declaration of Citizenship (PH-4183)
- Declaration of Eligibility for Expedited Licensure Process for a Military Member(PH-4279)
- Declaration of Eligibility for Expedited Licensure Process for a Spouse of a Military Member(PH-4280)
- PA Supervising Physician Form
- Duplicate or Replacement License Form (PH-4057)
- Affidavit of Retirement From Practice in Tennessee (PH-3460)
- Name and Address Change Request
- Application for Licensure as an Orthopedic Physician Assistant(PH-3562)
- Application for Licensure as a Physician Assistant(PH-3563)
- Instructions for Renewal Application
- Mandatory Practitioner Profile Questionnaire for Licensed Health Care Providers(PH-3585)
- Application Instructions for Licensure Reinstatement (PH-3556)
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Texas.
Texas
To be eligible for a PA License in Texas, an applicant must meet the following requirements:
- Successful completion of an educational program for physician assistants or surgeon assistants accredited by the Accreditation Review Commission on Education for the Physician Assistant, or by that committee's predecessor or successor entities
- Passage of PANCE within 6 attempts
- NCCPA Certification
- Any health care licenses held not subject to any type of disciplinary action
- Good moral and professional character
- Mentally and physically able to function safely as a PA
- Passage of the jurisprudence (JP) exam
- Have practiced at least 20 hours a week for 40 weeks in one of the two years preceding application
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Utah.
PA Licensure
Complete Application
Official Transcripts
Certification of completion of Education
NCCPA verification
Affidavit of Collaboration
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Vermont.
You MUST submit these forms in addition to completing the online application. If you are using the FCVS, you do not need to print out the Medical School Verification Form (UA #2) or the Post-Graduate Training Verification Form (UA #3). That information will be verified and included in the FCVS packet.
- PA Initial Application Forms
- PA CME Board Rule Requirements
- PA Notification of Termination of Employment Form
- Malpractice Reporting Form (Form A)
Act 123 of 2020 Updates Laws Regarding Physician Assistant Practice Agreements: Pending issuance of rules, the new law makes significant changes to the requirements for physician assistant supervision and the documentation that must be filed with the Board.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Virginia.
.Application and Fee – Complete the online application which includes paying the required
application fee of $130.00. Application fees may only be paid using Visa, MasterCard,
American Express or Discover.
2. Form L: Proof of Professional Education: This form can be found on the board website and
must be completed by your professional school as directed. This documentation should not be
faxed. If using FCVS this documentation will be provided. In the alternative, a letter from the
program director documenting completion of the educational coursework is acceptable
3. NCCPA: If you are a new applicant, or your previous Virginia license expired over 2 years ago,
you must request one of the following:
1) statement of current certification
OR
2) a letter of eligibility submitted DIRECTLY FROM the NCCPA, Inc., 12000 Findley Road,
Suite 200, Duluth GA 30097; (678) – 417-8100. Verification of current certification may be
mailed to the board office or emailed directly from NCCPA. Faxes are not acceptable. After
initial licensure, you must maintain a current NCCPA status or you will not be considered licensed
by the board. Personal copies of your certificate are not acceptable. If using FCVS a statement of
current certification will be provided.
Items 4-6 are not required if you have never practiced your profession and
you have never held licensure in another jurisdiction.
4. Employment Activity – List all activities from the date of graduation from your professional
school including but not limited to internships, employment, affiliations, periods of non-activity
or unemployment, observerships and volunteer service in the “Employment Activity” section of
the application beginning with your first activity following professional school graduation. If
you are employed by a group practice or locum tenens/traveler company, please list all locations
where you have provided service or held privileges. If you need additional space to record your
activities, follow this link to obtain a supplemental form and submit with your application:
Supplemental Form: https://www.dhp.virginia.gov/media/dhpweb/docs/med/forms/SupplementalForm.pdf
For applicants practicing as travelers or locum tenens, or if you are practicing telemedicine, have
the company you are affiliated with provide a complete list of all locations and dates where you
have provided service.
5. License Verification: Contact the applicable jurisdiction where you have been issued a license
topractice as a physical assistant to inquire about having documentation forwarded to the Virginia
Board of Medicine. Verification must come from the jurisdiction and maybe sent by email to
[email protected] , faxed to (804) 527-4426, or mailed. Please contact the
applicable jurisdictions to inquire about processing fees. Be sure to check with
VERIDOC.ORG as some states use this service for their license verifications in which case you
will not need to contact the Boards where you hold other licenses. If you are a new graduate with no
licenses in any state or US jurisdiction, you will not need to provide license verifications.
6. NPDB Self Query –
Complete the online Place a Self-Query Order form at https://www.npdb.hrsa.gov/..
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Washington.
Physician Assistant Application
Online Application Instructions
Apply Online
Only one of the following options is needed to obtain a license in Washington:
Option 1: Washington State Physician Assistant online application - for Washington State licenses only.
Option 2: Uniform Application for Physician Assistant State Licensure (UA) and Federation Credentials Verification - -This application aims to improve license portability by eliminating the need for physician to re-enter information when applying for licenses in multiple states.
Required Items to Apply
- The Washington State Department of Health requires that only the applicant or licensee may complete an attestation for an application, or for continuing education. This is a legal attestation. Completion of the attestation by anyone other than the applicant may constitute a reportable felony offense. The Department of Health can take action against people for perjury or for making a false statement they know to be false.
- Payment of application fees.
- In order to avoid delays, make your FSMB profile accessible to the Commission prior to application submission.
- You will need to be certified through the NCCPA to qualify for a license.
There are additional items you may need to complete your application.
If we need additional documentation, we will notify you by email.
Background Check
Washington State law authorizes the Department of Health to obtain fingerprint-based background checks for licensing purposes. This check may be through the Washington State Patrol and the Federal Bureau of Investigation. We may require this if you have lived in another state or if you have a criminal record in Washington State. This would be at your own expense.
Other Items May Include
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in West Virginia.
PHYSICIAN ASSISTANT LICENSURE REQUIREMENTS FOR THE STATE OF WEST VIRGINIA
All applicants for physician assistant licensure in the State of West Virginia shall provide evidence of the following:
1. Proof of graduation from an accredited program of instruction for physician assistants with a baccalaureate or master’s degree, as evidenced by a copy of the diploma;
2. Evidence of current certification from the National Certification Examination for Primary Care Physician Assistants (NCCPA), or evidence of current licensure in good standing from a state that does not require a physician assistant to maintain national certification; and
3. All Professional Practice, Character and Fitness requirements to practice as a physician assistant are met.
We do accept information from the Federation Credentials Verification Service (FCVS).
There are no exceptions to the above requirements except, at the discretion of the Board, a physician assistant may be licensed if he or she meets either of the following standards:
1. He or she is a graduate of an approved program of instruction in primary health care or surgery prior to July 1, 1994, has passed the certifying examination for a physician assistant administered by the National Commission on Certification of Physician Assistants (NCCPA), and either is currently certified by the NCCPA or has current licensure in good standing from a state that does not require a physician assistant to maintain national certification; or
2. He or she had been certified by the board as a physician assistant then classified as “Type B”, prior to July 1, 1983.
THE FOLLOWING MUST ALSO BE SUBMITTED WITH THIS APPLICATION:
1. A nonrefundable application fee in the amount of $250.00, payable to the West Virginia Board of Medicine. The Board accepts the following forms of payment: business checks; personal checks; cashier’s checks; credit cards; and money orders payable to the WV Board of Medicine;
2. A legible copy of your physician assistant diploma;
3. Documentation of your current certification by the National Commission on Certification of Physician Assistants (NCCPA) or verification that you hold a current license in good standing from a state that does not require a physician assistant to maintain NCCPA certification;
4. A copy of your birth certificate, certificate of naturalization, or passport;
5. Check the website of each state or jurisdiction where you now hold or have ever held certification or licensure as a physician assistant, regardless of the statue of that license, for its instructions on verification/certification of your license to another state board. Verification of licensure is also accepted from VeriDoc, for states that use this service, which may be requested online at www.veridoc.org; and
6. A National Practitioner Data Bank (NPDB) self-query report generated within thirty days of submission to the Board. Please follow the instructions given for requesting a self-query at https://www.npdb.hrsa.gov/ext/selfquery/SQHome.jsp. A pdf of the self-query report may be forwarded to the Physician Assistant Licensure Analyst, or you may request a mailed copy so that the self-query report is mailed directly to you. You must then mail (do not fax) all of the original report (not photocopies) directly to this office.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Wisconsin.
Wisconsin Department of Safety and Professional Services
APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
• Application (Form #580) and appropriate fee
• Letters from all State Boards where licensed, active and
inactive
• Wisconsin Statutes and Rules Examination
• Certificate of Professional Education (Form #1504) (not
applicable to Re-registration applicants)
• National Examination scores (go to: www.nccpa.net) (not
applicable to Late Renewal applicants-lic expired 5+ yrs)
• Malpractice Suits or Claims (Form #2829) and copies of malpractice
suit, court documents with allegations and settlement, if applicable
• Convictions and Pending Charges (Form #2252), if applicable
• Is name on all credentials the same? If not, submit certified copy of
marriage certificate, divorce decree, etc.
Colorado Mesa University has determined that the Master of Physician Assistant Studies program does meet licensing requirements in Wyoming.
WYOMING BOARD OFMEDICINE
CHECKLIST OF REQUIRED DOCUMENTS FOR PHYSICIAN ASSISTANT LICENSURE APPLICATION:
1) Notarized Affidavit Form including photograph taken within the past 3 months
2) Citizenship & Alien Status Declaration Form
3) Verification of NCCPA certification*
4) Verification of Physician Assistant Training*
5) 3 Reference questionnaires (2 from an MD or DO and 1 from an MD, DO or PA)*
6) Verification of all state licenses*
7) Any and all supplemental documentation to “yes” answered application questions
8) Application fee
9) Application Form(s) from Supervising Physician(s)
* Items must come directly from the institution/facility/state board/author only.