Physician Assistant: Temporary Permit

Recent graduates may apply for a temporary permit which authorizes them to practice as a physician assistant only in those settings where the supervising physician is physically present on the premises and is immediately available to the physician assistant when needed. The temporary permit does not authorize the holder to prescribe or dispense drugs and shall be valid only until the issuance of the results of the first certification examination scheduled by the nccpa following the applicants' graduation from an accredited physician assistant program. The temporary permit is not renewable. Individuals who do not successfully complete the examination, or who do not attend the examination, cannot be issued a new temporary permit.

First Name:

Middle Name:

Last Name:

Maiden Name:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

U.S. Social Security No:

Date Of Birth:

MonthDayYear

Telephone Number(Where you can be reached mon. - fri. 8:30 a.m.- 4:30 p.m.)

Please enter a valid phone number.Format: (000) 000-0000.

Have you ever taken the certification examination of the national commission on certification of physician assistants (nccpa)?

If yes - what was the date of examination?

MonthDayYear

If no - what is the date when the examination will be taken?

MonthDayYear

What is the name of the physician who will supervise your work under the temporary permit?

Pursuant to Public Law 100-93, the Federal Government requires all states to report disciplinary actions to the Inspector General for Health and Human Services or risk losing Federal medicaid contributions. Although the disclosure of your social security number on this application is voluntary, Public Law 100-93 also requires the Department of Public Health to request the disclosure of your number as data that would then be available to the National Practitioner Data Bank in the event that disciplinary action should be taken against your Connecticut license. You are not required by any law to disclose your social security number, but should you decide to do so, it will be used for identification purposes only, including verifying and retrieving information.

All of the above statements contained herein are true and correct to the best of my knowledge and belief

Signature:

Please enter full legal name

Date:

MonthDayYear

On this day* day of month* , 20 year* applicant's name*(applicant's name) personally appeared before me, who being duly sworn says that she/he is the person referred to in the foregoing application and that the statements made herein are true in every respect.

Applicant Signature:

Please enter full legal name

Sworn to before me this day* day of month* 20 year* .

Signature of notary public:

My Commission expires:

MonthDayYear

This application together with the fee of $150.00 in the form of a certified check or money order made payable to “treasurer, state of ct” should be sent to:

DEPARTMENT OF PUBLIC HEALTH
PHYSICIAN ASSISTANT LICENSURE- REMITTANCE UNIT
410 CAPITOL AVE., MS# 12MQA
P.O. BOX 340308
HARTFORD, CT 06134

Public Health: Application For Physician Assistant Temporary Permit