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SECTION II: INSTRUCTIONS TO THE SUPERVISING PHYSICIAN

By completing the information below, you are certifying that the permittee will be employed under the supervision of a physician who

is licensed and currently registered to practice in New York State and that the employer agrees to abide by the conditions stipulated

on the permit.

Limited permits expire one year from the date of issuance, or upon notice to the applicant by the Department that the application for

licensure has been denied. See applicant instructions for further information.

If applicant requests more than one employer at the same time, a separate Form 5 must be completed by each supervising physician

and each employer or physician.

The applicant may not practice as a physician assistant until the limited permit is issued.

CERTIFICATION OF SUPERVISION - (To Be Completed By Supervisor)

Applicant's name: ___________________________________________________________

Employer:

Name: _____________________________________________________________________________________________________

(Enter full name - no initials)

Street: _____________________________________________________________________________________________________

City: ________________________________________________ State: __________ Zip code: ____________ - _______________

Telephone: __________________________ Fax: ___________________________ E-mail: _________________________________

If practice site is different from employer address (item 2), provide that address:

Name: _____________________________________________________________________________________________________

Street: _____________________________________________________________________________________________________

City: ________________________________________________ State: __________ Zip code: ____________ - _______________

Telephone: __________________________ Fax: ___________________________ E-mail: _________________________________

Direct supervision will be provided by:

Name of supervising physician: _________________________________________________________________________________

(Please print or type)

CERTIFICATION

I certify that the applicant named above will be employed under my supervision. I am a licensed physician currently registered in

New York State and agree to abide by the conditions stipulated on the permit.

I declare and affirm that the statements made in the foregoing certification are true, complete and correct. Any false or

misleading information in, or in connection with this certification may be cause for disciplinary action against my license.

Signature of supervising physician __________________________________________________________________________________

Date _______ / _______ / _______

N.Y. License No. _____________________

Employer or appointed designee: __________________________________________________________________________________

(Please print or type)

Signature of employer: ______________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,

NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Registered Physician Assistant Form 5, Page 2 of 2, Rev. 8/15

Physician Assistant Form 5 - Application For Limited Permit - New York The State Education Department Page 2