Form Doh 663-072 - Osteopathic Physician Assistant Remote Site Request Form


Osteopathic Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
Osteopathic Physician Assistant Remote Site Request Form
A remote site is a practice location where the osteopathic physician is present less than 25% of the practice time of
RCW 18.57A.035
the certified osteopathic physician assistant. See
Name of Physician Assistant
License #
Primary Supervisor Name
License #
Name of Remote Site
Phone (enter 10 digit #)
Address of remote site
Zip Code
Remote Site Practice Questions:
Will the Osteopathic Physician Assistant practice in more than one remote site setting? c Yes
c No
If yes, list all remote sites. If more than two remote sites, please attach additional pages.
What percentage of time per
What percentage of time per
Practice Sites
What percentage of time per
week does the supervising
week are the supervising
(Please mark all that is
week does the Osteopathic
physician spend at each
physician at each setting at
applicable to this request.)
PA spend at each setting?
the same time?
Supervising physician’s
primary practice site:
Remote Site Address:
Remote Site Address:
DOH 663-072 August 2016
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