Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access printable pdf download

Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access

Rev 4/15

STATE BOARD OF PHYSICAL THERAPY

P. O. BOX 2649

HARRISBURG, PA 17105-2649

717-783-7134

PHYSICAL THERAPIST

APPLICATION FOR

CERTIFICATE OF AUTHORIZATION

DIRECT ACCESS

TO TREAT BY

REQUIREMENTS -

Applicant holds a current license to practice physical therapy in Pennsylvania and such

license has been (and must continue to be) maintained in good standing.

Applicant has passed the national physical therapy examination. If applicant passed

the examination prior to 1990, a board approved course of at least 10 hours must be

completed on the appropriate evaluative procedures to treat a person without a referral.

The course must be completed within the 24 months immediately preceding the date of

application. Complete Part Four of the application and submit the required documentation.

Applicant has practiced physical therapy in the delivery of patient care on a continuous

basis for at least the two years (24 months) immediately preceding submission of this

application. At least 200 hours of direct patient care in each 12 month period are required.

Applicant is covered by professional liability insurance in the minimum amount required

Section 9(b)(4)(iii.1)of the Physical Therapy Practice Act and Section 40.69 of the Board’s

regulations. See information on next page. Coverage shall remain in effect as long as

licensee has the certificate

INSTRUCTIONS -

Print information requested in PARTS ONE through FOUR of the application and sign/date the

“Verification” at bottom of page 2.

If your name appears differently on the application or documents, submit a copy of the

official document which authorized the change.

FEE: Submit a check or money order in the amount of $30.00 payable to

"Commonwealth of Pennsylvania" with your completed, ORIGINAL application.

Please Note: If a pending application is older than one year from the date submitted and the

applicant wishes to continue the application process, the Board shall require the applicant to

submit a new application including the required fee.

In order to complete the application process, many of the supporting documents associated

with the application cannot be more than six months from the date of issuance.

: Include documentation per instruction 2 and/or PART FOUR, if applicable.

ENCLOSURES

MAIL TO: State Board of Physical Therapy, P.O. Box 2649, Harrisburg, PA 17105-2649

OR for overnight delivery …..2601 North Third Street, Harrisburg, PA 17110.

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Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access