Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development Page 11
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13ALASKA STATE MEDICAL BOARD
Department of Community and Economic Development
Office Use Only
Division of Occupational Licensing
3601 C Street - Suite 722
Anchorage AK 99503-5934
(907) 269-8163
E-Mail: license@dced.state.ak.us
PHYSICIAN ASSISTANT - CERTIFIED
VERIFICATION OF HOURS OF SUPERVISION
INSTRUCTIONS:
In accordance with 12 AAC 40.410 (e and f), Physician Assistants must complete 160 hours of
direct and immediate supervised work before practicing remote. Please complete this form and return to the address
above. You must hold a valid permit before working.
PHYSICIAN ASSISTANT
COLLABORATING PHYSICIAN
Name (Last, First, MI)
Name (Last, First, MI)
Address
Address
City/State/Zip
City/State/Zip
Telephone:
Telephone:
DOCUMENTED HOURS OF SUPERVISED WORK
Date
No. Hrs
Date
No. Hrs
Date
No. Hrs
Date
No. Hrs
Total Hours Submitted:___________________________________________
__________________________________________
____________________________________________
Signature, Physician Assistant
Date
Signature, Collaborating Physician
Date
08-4226 g (Rev 11/2000)
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