Form Doh 663-072 - Osteopathic Physician Assistant Remote Site Request Form printable pdf download

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

Osteopathic Credentialing

P.O. Box 47877

Olympia, WA 98504-7877

360-236-4700

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

City

State

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

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?

setting?

the same time?

Supervising physician’s

primary practice site:

Remote Site Address:

DOH 663-072 August 2016

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