Physician Assistant Initial App - Florida Board of ...
A R ME D
FORCES
LICENSING
Are you an active duty member of the United States Armed Services? Are you a veteran of the United States Armed Services?
Are you the spouse of a veteran of the United States Armed Services? Are you the spouse of an active member of the United States Armed Services? If you answered "Yes" to any of these questions, you may qualify for a reduction in Health's commitment to serving members and veterans of the United States Armed
Forces and their families online at
Physician Assistant
Application for Licensure
Board of Medicine P.O. Box 6330
Tallahassee, FL 32314-6330 Fax: 850-488-0596
Email: BOM_InitialApps@
Do Not Write in this Space For Revenue Receipting Only
Select one Physician Assistant (1512) application type: $305.00
Full Licensure
Temporary Licensure Date PANCE will be taken: ____________
MM/DD/YYYY
Temporary licensure applicants are required to request direct verification of their exam registration be sent to the council office.
Total fee of $305.00 includes the following:
Application Fee (non-refundable) $100.00
Licensure Fee
$200.00
Unlicensed Activity Fee
$5.00
Fees must be paid in the form of a cashier's check or money order, made payable to the Department of Health. Requests for a refund must be made in writing. Fees are refundable for up to three years from the date of receipt.
1. PERSONAL INFORMATION
Name: ______________________________________________________________________ Date of Birth: _______________
Last/Surname
First
Middle
MM/DD/YYYY
Mailing Address: (The address where mail and your license should be sent)
___________________________________________________ _______ __________________________________
Street/P.O. Box
Apt. No. City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Home/Cell Telephone (Input without dashes)
Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website.)
___________________________________________________ _______ __________________________________
Street
Suite No. City
________________________________ ________ ___________________ _________________________________
State
ZIP
Country
Work/Cell Telephone (Input without dashes)
EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
Gender: Male Female
Race:
Native Hawaiian or Pacific Islander American Indian or Alaska Native Two or More Races
Hispanic or Latino Black or African American
White Asian
Email Notification: To be notified of the status of your application by email check the "Yes" box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the board office.
Yes
No Email Address: ____________________________________________________
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.
DH-MQA 2000, Revised 12/2021, Rules 64B8-30.003 and 64B15-6.003, F.A.C.
Page 3 of 18
2. SOCIAL SECURITY DISCLOSURE
This information is exempt from public records disclosure.
Pursuant to Title 42 United States Code ? 666(a)(13), the department is required and authorized to collect Social Security Numbers relating to applications for professional licensure. Additionally, section (s.) 456.013(1)(a), Florida Statutes (F.S.), authorizes the collection of Social Security numbers as part of the general licensing provisions.
Last Name: _____________________________________________________________
First Name: _____________________________________________________________
Middle Name: ___________________________________________________________
Social Security Number: __________________________________________________
(Input without dashes)
Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, ? 653 and 654; and s. 456.013(1), 409.2577, and 409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for license identification pursuant to Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317). Clarification of the SSA process may be reviewed at or by calling 1-800-772-1213.
DH-MQA 2000, Revised 12/2021, Rules 64B8-30.003 and 64B15-6.003, F.A.C.
Page 4 of 18
Name: _____________________________________________
3. APPLICANT BACKGROUND
A. List any other name(s) by which you have been known in the past. List name changes including marriage, naturalization, divorce, or any other means. Attach additional sheets if necessary.
_______________________________________________________________________________________
Provide a copy of the legal name change document for each name change.
B. Do you hold, or have you ever held a license to practice medicine as a physician assistant or any other
regulated professional license(s)? Yes
No
C. List all regulated professional licenses (active, inactive, or lapsed).
License Type
License #
State/Jurisdiction or Country
Original Date
Expiration
Issued
Date
(MM/DD/YYYY) (MM/DD/YYYY)
Status of License
Submit a License Verification form to ALL state(s) of licensure. License verifications must be received directly from the licensing authority regardless of the status of the license. If no license/registration/certification was required during your employment, request that the state board provide such statement directly to this office. See the "License Verification Request" form found at the end of the application. A copy of your license will not be accepted in lieu of official verification from the licensing agency.
D. Have you ever discontinued practice for any reason for a period of one month or longer? Yes
No
E. Have you had a judgement entered against you for medical malpractice when the incident(s) of malpractice
occurred after November 2, 2004?
Yes
No
F. Within the last ten years have you had any liability claims or actions for damages for personal injury settled or
finally adjudicated in an amount that exceeds $100,000? Yes
No
If you responded "Yes" to question E or F, you must provide the following:
A copy of the Complaint(s), Amended Complaint(s), and Judgement. If litigation is pending, the attorney representing the case must submit a letter addressed to the Council on Physician Assistants explaining the current litigation status.
A written self-explanation listing your involvement in each case.
G. If you have ever served in the United States (U.S.) Military or Public Health Service (PHS), have you ever
been disciplined by any branch of the U.S. Military or PHS? Yes
No
N/A
If "Yes," provide the following:
A self-explanation on a separate sheet providing accurate details (including, but not limited to, the date(s), location(s), and specific circumstances).
Documentation from the U.S. Military/PHS regarding the charge(s)/event(s).
DH-MQA 2000, Revised 12/2021, Rules 64B8-30.003 and 64B15-6.003, F.A.C.
Page 5 of 18
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