Physician Assistant : License Application

  • Public Health: Physician Assistant - License Application

    DPH Data Management and Governance (PLIS)

  • Physician Assistant
    Email: dph.healingarts@ct.gov
    Website: www.ct.gov/dph/license
    Physician Assistant License Application

     


  • TAPE A RECENT PHOTO OF APPLICANT HERE.

    DO NOT STAPLE

  • This application must be accompanied by a check or money order in the amount of $190.00, made payable to “Treasurer, State of Connecticut."

    Return completed application and fee to:

    CT DPH, Physician Assistant Application Processing, 410 Capitol Ave., MS# 12MQA, PO Box 340308, Hartford, CT 06134

  • Format: (000) 000-0000.
  • Gender:*
  • Date of Birth:*
     - -
  • Ethnicity:*
  • Race: Please check all that apply*
  • Have you held a Connecticut physician assistant license in the past?*
  • Are you now or have you ever been licensed as a physician assistant in any state?*
  • Degree Date:*
     - -
  • Degree Date:*
     - -
  • Have you completed at least 60 hours of didactic instruction in pharmacology for physician assistant practice?*
  • Have you taken the certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA)?*
  • Exam Date:
     - -
  • Did you Pass?
  • Are you certified by the NCCPA (please note that you will need to maintain NCCPA certification for renewal of your license)?*
  • Have you ever been censured, disciplined, dismissed or expelled from, had admissions monitored or restricted, had privileges limited, suspended or terminated, been put on probation, or been requested to resign or withdraw from any of the following: Any hospital, nursing home, clinic, or similar institution; Any health maintenance organization, professional partnership, corporation, or similar health practice organization, either private or public; Any professional school, clinical clerkship, internship, externship, preceptorship; or postgraduate training program; Any third party reimbursement program, whether governmental or private?*
  • Have you ever had your membership in or certification by any professional society or association suspended or revoked for reasons related to professional practice?*
  • Has any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction, limited, restricted, suspended or revoked any professional license, certificate, or registration granted to you, or imposed a fine or reprimand, or taken any other disciplinary action against you?*
  • Have you ever, in anticipation or during the pendency of an investigation or other disciplinary proceeding, voluntarily surrendered any professional license, certificate or registration issued to you by any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction?*
  • Have you ever been subject to, or do you currently have pending, any complaint, investigation, charge, or disciplinary action by any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction or any disciplinary board/committee of any branch of the armed services? You need not report any complaints dismissed as without merit?*
  • Have you ever entered into, or do you currently have pending, a consent agreement of any kind, whether oral or written, with any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, any branch of the armed services or a foreign jurisdiction?*
  • Have you ever been found guilty or convicted as a result of an act which constitutes a felony under the laws of this state, federal law or the laws of another jurisdiction and which, if committed within this state, would have constituted a felony under the laws of this state?*

  • If you answered yes to any of the above questions regarding your professional history, please provide full details and provide supporting documentation (e.g. certified court copy with court seal affixed, complaint,answer, judgment, settlement or disposition) that will assist this office’s review.

  • NOTARIZATION: On this   *   day of   *   *   , the above referenced individual personally appeared before me, who being duly sworn says that she/he is the person referred to in the foregoing application and that the photograph attached hereto is a true picture of self and that the statements made herein or any document attached hereto are true in every respect. 

    Sworn to before me this   *   day of   *     20*   

  • My Commission Expires:*
     - -
  •  
  • Should be Empty: