Or. Admin. Code § 847-050-0021 - Documents to be Submitted for Licensure
The documents submitted must be legible and no larger than 8
½" x 11". All documents and photographs will be retained by the
(1) Application: Completed
formal application provided by the Board . Required dates must include month,
day, and year.
(2) Birth
Certificate: A copy of birth certificate and a copy of Change of Name
documentation, Marriage Certificate, or Divorce Decree if the applicant's name
has been changed by court order, adoption, marriage, divorce, etc.
(3) Photograph: A close-up, passport-quality
photograph, front view, head and shoulders (not profile), with features
distinct, taken within 90 days preceding the filing of the
application.
(4) Legible
fingerprints as described in OAR
847-008-0068 for the purpose of
a criminal records background check.
(5) The results of a Practitioner Self-Query
from the National Practitioner Data Bank.
(6) The results of a Physician Data Center
Query from the Federation of State Medical Boards.
(7) The applicant must ensure the following
required official documents are sent to the Board directly from:
(a) The physician assistant or physician
associate education program:
(A) Proof of
completion of a physician assistant or physician associate education program as
specified in OAR 847-050-0020(1)
and which includes degree issued, date of degree, dates of attendance, dates
and reason of any leaves of absence or repeated years, and dates, name and
location of education program if a transfer student.
(B) A Verification of Education form; which
must include information about an applicant's knowledge base, clinical skills,
medical judgement, professionalism, and ethics; including any concerns
regarding possible impairment in the applicant's ability to safely practice
their profession. If the school is unable to complete the form or the Board
determines that it is unacceptable, a copy of the transcripts may be
acceptable.
(b) Official
Examination Certification: An official Examination Certification of the
Physician Assistants National Certifying Examination (PANCE), showing the
examination score, is required directly from the National Commission on
Certification of Physician Assistants (NCCPA).
(c) If requested by the Board , a letter
verifying licensure in good standing from the state or states of all prior and
current health-related licensure. Verification, sent directly from the boards,
must show license number, date issued, examination grades if applicable and
status.
(d)
(A) The Director or other official for
practice and employment in hospitals, clinics, etc. in the United States and
foreign countries: A currently dated original letter (a copy is not
acceptable), sent directly from the hospital/clinic, must include a statement
of good standing and specific beginning and ending dates of practice and
employment, for the past five (5) years only.
(B) If the applicant has ceased practice for
more than two (2) years, employment verifications will be required for the past
ten (10) years.
(C) If such
verification is unavailable or incomplete, provide three reference letters from
physicians, physician assistants, or physician associates in the local medical
community who are familiar with the applicant's practice and who have known the
applicant for more than six months.
(8) Any other documentation or explanatory
statements as required by the Board , including but not limited to medical
records and criminal or civil records.
Notes
Statutory/Other Authority: ORS 677.265 & ORS 677.512
Statutes/Other Implemented: ORS 677.512
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