Kan. Admin. Regs. § 100-28a-2

Current through Register Vol. 43, No. 49, December 5, 2024

Section 100-28a-2 - Application

(a) Each application for li-censure as a physician assistant shall be submitted on a form provided by the board. The form shall contain the following information:

(1) The applicant's full name;

(2) the applicant's home address and, if different, the applicant's mailing address;

(3) the applicant's date and place of birth;

(4) the applicant's social security number, individual tax identification number, or nondriver identification number, if the applicant is advised that providing a social security number is voluntary pursuant to K.S.A. 74-139 and 74-148, and amendments thereto, and that if the social security number is provided, the agency may provide this number to the Kansas department of social and rehabilitation services for child support enforcement purposes and to the Kansas department of revenue's director of taxation;

(5) the issue date; state, territory, the District of Columbia, or other country of issuance; and the identifying number on any license, registration, or certification issued to the applicant to practice any health care profession;

(6) documentation of any prior acts constituting unprofessional conduct as defined in K.A.R. 100-28a-8;

(7) the applicant's daytime telephone number;

(8) the names of all educational programs recognized under K.A.R. 100-28a-3 that the applicant attended, including the program from which the applicant graduated, the degree awarded to the applicant, and the date of graduation;

(9) notarized certification that the applicant has completed a physician assistant program from a postsecon-dary school recognized under K.A.R. 100-28a-3;

(10) a list of all attempts to gain board certification recognized under K.A.R. 100-28a-4 and an official copy of the applicant's board certification; and

(11) a notarized release authorizing the board to receive any relevant information, files, or records requested by the board in connection with the application.

(b) Each applicant shall submit the following with the application:

(1) The fee required by K.A.R. 100-28a-1;

(2) an official transcript from an educational program approved by the board as specified provided in K.A.R. 100-28a-3 that specifies the degree awarded to the applicant;

(3) a verification from each state, country, territory, or the District of Columbia where the applicant has been issued any license, registration, or certification to practice any health care profession;

(4) a photograph of the applicant measuring two inches by three inches and showing the head and shoulder areas only. The photograph shall be taken within 90 days before the date of application; and

(5) evidence provided directly to the board from the national commission on certification of physician assistants that the applicant has passed the physician assistant national certifying examination.

(c) The applicant shall sign the application, under oath and shall have the application notarized.

Kan. Admin. Regs. § 100-28a-2

Authorized by and implementing K.S.A. 2008 Supp. 65-28a03; implementing K.S.A 65-28a04; effective, T-100-2-13-01, Feb. 13, 2001; effective June 1, 2001; amended Jan. 4, 2010.