Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access (Page 3 of 4) in pdf

Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access Page 3

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

APPLICATION FEE - $30.00

Personal Check or Money Order made payable to "Commonwealth of Pennsylvania."

Application fees are not refundable. NOTE: A processing fee of $20.00 will be charged for any check or money order

returned unpaid by your bank, regardless of the reason for non-payment. If a pending application is older than one year from the

date submitted online 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. All background check documents cannot be older than 90 days from the date of

issuance.

PART ONE -

P T 0

PHYSICAL THERAPIST LICENSE NUMBER:

(PT license must be current/unexpired; NOT expired or inactive)

NAME________________________________________________________________

DAYTIME PHONE _______________

Last

First

Middle

Maiden

ADDRESS __________________________________________________________________________________________

Street

City

State

Zip Code

SOCIAL SECURITY#______________________BIRTHDATE______________________EMAIL______________________

PART TWO - Practice of Physical Therapy in the Delivery of Patient Care

My signature here _____________________ certifies that I have practiced physical therapy in the delivery

of patient care on a continuous basis for at least the two years (24 months) immediately preceding this

application. I have delivered a minimum of 200 hours of direct patient care during each 12 month period.

Below, provide dates of employment, name and ADDRESS of employer, position title and duties/responsibilities

of each employment for the immediate past two years, to date. Show experience for at least the 24 months

immediately preceding submission of this application.

Dates

Employer Name and ADDRESS

Position Title

Duties and Responsibilities of Direct Patient Care

From / To

Mo. & Yr.

Application For Physical Therapist Certificate Of Authorization To Treat By Direct Access Page 3

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