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INFORMATION/REQUIREMENTS AND INSTRUCTIONS - PHYSICAL THERAPY LICENSE

Access this form via website at: cca.hawaii.gov/pvl

INFORMATION/REQUIREMENTS

DEFINITIONS No person shall practice physical therapy in this state unless the person is appropriately licensed.

"Physical therapist" means a person who is licensed to practice physical therapy in this State.

"Physical therapy" or "physical therapy services" means the examination, treatment, and instruction of human beings

to detect, assess, prevent, correct, alleviate, and limit physical disability, bodily malfunction, pain from injury, disease,

and any other physical or mental condition as performed by a physical therapist appropriately licensed under this

chapter. It includes but is not limited to:

(1)

Administration, evaluation, modification of treatment, and instruction involving the use of physical

measures, activities, and devices, for preventive and therapeutic purposes; provided that should the care

or treatment given by the physical therapist contravene treatment diagnosed or prescribed by a medical

doctor, osteopath, or as determined by the Board, the physical therapist shall confer with the professional

regarding the manner or course of treatment in conflict and take appropriate action in the best interest of

the patient; and

(2) The provision of consultative, educational, and other advisory services for the purpose of reducing the

incidence and severity of physical disability, bodily malfunction, or pain.

Hawaii does not reciprocate with any other state or country. Each applicant is required to meet the education and

national examination requirements according to Hawaii laws and rules. Licensure requirements are subject to

change as a result of new laws or rules, or new policies and procedures adopted by the Department of Commerce

and Consumer Affairs ("Department") in cooperation with the Board of Physical Therapy ("Board"). All applicants

must meet current licensure requirements.

EDUCATION

Submit proof of one of the following:

(1) Graduated from a Commission on Accreditation in Physical Therapy Education (CAPTE) accredited physical

therapy program. ARRANGE with your school or college to send a certified transcript (in the English

language) showing graduation date and physical therapy degree conferred, directly to the Board.

•

If you have just graduated or will be graduating soon, have your school send the following directly to

the Board by the application filing deadline:

An official letter of completion by the license exam date which states that you are in your final year

of that physical therapy program and have completed the physical therapy program which at the

time of graduation was accredited by CAPTE. This letter must be received in the Board's office first

in order to be deemed eligible to sit for the exam.

ii.

An official final transcript verifying degree conferred must follow and be received prior to

a license being issued; OR

(2) Graduated from a school or college of physical therapy located outside the U.S. and that is not CAPTE

accredited:

•

You must submit your credentials to a Board approved Credentials Evaluation Service organization. The

Board will accept a credentials evaluation report from those organizations listed below. ARRANGE to

have the evaluation service forward your certified credentials evaluation report directly to the Board.

•

Your credentials evaluation report must comply with Hawaii's requirements; therefore, a report

prepared for another state will not be accepted. The report must state that your education is

equivalent to an accredited program in physical therapy in the U.S. The evaluation shall be

prepared within one year from the date of the application's submission.

(CONTINUED ON PAGE 2)

PT-02 0519R

Credentials Evaluation Service Organizations:

International Educational Research Foundation, Inc.

P.O. Box 3665

Culver City, CA 90231-3665

Phone: (310) 258-9451

Fax: (310) 342-7086

Website: www.ierf.org

International Consultants of Delaware

3600 Market Street, Suite 450

Philadelphia, PA 19104-2651

Phone: (215) 243-5858

Website: www.icdeval.com

Foreign Credentialing Commission on Physical Therapy

124 West Street South, 3rd Floor

Alexandria, VA 22314

Phone: (703) 684-8406

Fax: (703) 684-8715

Website: www.fccpt.org

ENGLISH

LANGUAGE

COMPETENCY

If your physical therapy school or college is in a country, state, or province where the official language is other than

English, applicants must take and pass one of the following English language proficiency tests: Test of English as a

Foreign Language (TOEFL) with the passing score for each exam as recommended by the FSBPT; or the TOEFL

internet based test with a passing score as recommended by the FSBPT. For TOEFL information, contact:

Educational Testing Service (ETS)

P.O. Box 6151

Princeton, NJ 08541-6151

Phone: (609) 771-7100

Fax: (610) 290-8972

Web: www.ets.org

FILING DEADLINE

AND EXAM

INFORMATION

Please refer to the posted application filing deadlines and examination dates on our website at: cca.hawaii.gov/pvl.

If your application requires additional review time, please be advised to file your application as early as possible.

EXAMINATION Electronic testing is provided on set dates throughout the U.S. The test center for Hawaii is located on Oahu. To

After the Board has determined that you are eligible to sit for the exam, the Federation of State Boards of Physical

Therapy (FSBPT) will be notified of your eligibility and will send you an Authorization to Test ("ATT") letter.

You must sit for the exam within your eligibility period/date as indicated on your Authorization to Test. If

you fail to do so, you must contact the Board and re-register for the exam.

Please be advised that effective January 1, 2016, the FSBPT is implementing two new eligibility requirements (in

addition to the current requirements):

(1) lifetime limit of taking the exam a maximum six (6) times (this number is retroactive);

(2) low score limit of two (2) very low scores will not be allowed to test again.

Please note that the FSBPT's eligibility requirements are not the same as Hawaii's requirements for licensure

(pursuant to Hawaii Administrative Rules §16-110-20), however, in order to meet Hawaii's requirements for licensure,

all applicants must provide proof of taking and passing the physical therapist licensure examination.

If you have questions about the FSBPT's eligibility policies, please contact the FSBPT directly at:

examregistration@fsbpt.org. You may also visit their website at: https://www.fsbpt.org/.

(CONTINUED ON PAGE 3)

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EXAM WAIVER If you have already taken the NPTE and your score meets or exceeds the FSBPT's criterion - referenced passing score

requirement and you hold or ever held a physical therapy license in the United States and you meet the education

requirement, the Board will consider issuance of license through the exam waiver provision. Contact the FSBPT

Score Transfer Service to have your scores transmitted directly to the Board. An application for the FSBPT Score

Transfer Service can be made on the internet at the website below or by contacting them directly.

FSBPT Score Transfer Service

124 West Street South, 3rd Floor

Alexandria, VA 22314

Phone: 1-703-739-9420

Email: scoretransfer@fsbpt.org

Website: www.fsbpt.org

TEMPORARY

LICENSE

You may apply for a temporary license by providing the Board with either:

AGE OF MAJORITY

AND U.S. CITIZEN

In addition to the education and examination requirements, an applicant shall be beyond the age of majority (18

years of age) and a United States citizen, a United States national, or an alien authorized to work in the United States.

If you are not a citizen or national of the United States or alien authorized to work in the United States you may be

granted conditional approval pending receipt of your Social Security Number and authorization to work in the U.S.

Reforms in the immigration laws of the United States have led to new requirements for aliens who seek to enter the

United States for the purpose of performing labor as a health-care worker, including physical therapists. Federal

law mandates that any such alien is inadmissible from the country unless the alien presents a certificate from the

CGFNS International, or a certificate from an equivalent independent credentialing organization approved by the

Attorney General (See 8 U.S.C. 1182(a)(5)).

(CONTINUED ON PAGE 4)

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To apply for a temporary physical therapist license, submit a completed Statement of Supervising Licensed Physical

Therapist from your proposed supervising physical therapist and attach the additional $50 fee.

Only one temporary license will be issued per applicant. A temporary license shall expire within six months of its

effective date or be terminated at an earlier date pursuant to §16-110-40(d), HAR including the applicant's failure to

pass the NPTE exam. Any request for an extension of a temporary license will require Board review.

Please note: A temporary license shall not be issued to a person who is not a United States citizen, a United States

national or an alien authorized to work in the United States.

For more information on the requirements for temporary licenses, please refer to §16-110-40, HAR.

(1) The documents and evidence of qualifications listed in §16-110-20(b)(1) or (2), Hawaii Administrative Rules

("HAR") and evidence that you submitted to the Board either an application to take the licensure

examination within six months or evidence showing that you have taken the licensure examination and are

awaiting its results; or

(2) For examination waiver, evidence that the applicant has fulfilled the requirements of section 16-110-20(h),

Hawaii Administrative Rules.

CGFNS International

3600 Market Street, Suite 400

Philadelphia, PA 19104-2651

Phone: (215) 222-8454

Website: www.cgfns.org

The following organization has been identified to be an equivalent independent credentialing organization and is

authorized to issue certificates (See 8 C.F.R. section 212 15(e)(3)):

Foreign Credentialing Commission on Physical Therapy

124 West South Street, 3rd Floor

Alexandria, VA 22314

Phone: (703) 684-8406

Fax: (703) 684-8715

Website: www.fccpt.org

Filing Instructions

APPLICATION

FORM

Complete the on-line fillable application or print legibly in black ink.

•

Failure to provide all the requested information will delay the processing of your application.

Indicate what you are applying for:

•

Applying for endorsement: Passed National Physical Therapy Examination (NPTE). You must indicate which

state and on what date you passed the exam.

•

Applying for exam for the first time.

Applying for exam, failed exam. You must indicate the state or country and the date(s) you failed the exam.

•

Applying for a temporary license.

SOCIAL

SECURITY

NUMBER

Your Social Security Number is used to verify your identity for licensing purposes and for compliance with the below

laws. For a license to be issued you must provide your Social Security Number or your application will be

deemed deficient and will not be processed further.

The following laws require that you furnish your Social Security Number to our agency:

FEDERAL LAWS:

42 U.S.C.A. §666 (a)(13) requires the Social Security Number of any applicant for a professional license or

occupational license be recorded on the application for license; and

If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security

Number as part of the mandatory reporting we must do to the Healthcare Integrity and Protection Data Bank (HIPDB),

of any final adverse licensing action against a licensed health care practitioner.

HAWAII REVISED STATUTES ("HRS"):

§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational

license be recorded on the application for license; and

§436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security Number if

the licensing authority is authorized by federal law to require the disclosure (and by the federal cites shown above,

we are authorized to require the Social Security Number).

-4-

(CONTINUED ON PAGE 5)

RELEASE OF

INFORMATION

If an agency or individual is assisting you with the licensure process, we will not be able to release any information

to them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of

Information to Third Party, sign and date it.

If you are applying for a license through exam, submit the $50 non-refundable application fee. License fees will

be assessed after passage of the examination.

If you are applying for a license through the exam waiver provision, attach appropriate amount made payable to:

COMMERCE AND CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a U.S. financial institution.)

FEES

If you expect to be licensed in an ODD-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300

($50 - Application Fee + $85 - License Fee + $100 - Compliance

Resolution Fund + $65 - 1/2 Renewal)

If you expect to be licensed in an EVEN-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $185

($50 - Application Fee + $85 - License Fee + $50 - Compliance Resolution Fund)

The $50 Application Fee is non-refundable.

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the

payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for

your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required

licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service

charge will be assessed for payments that are dishonored for any reason.

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by the

Hawaii Administrative Rules, Title 16, Chapter 201, and/or Hawaii Revised Statutes. Your written request for a hearing

should be directed to the agency that issues your license and must be made within 60 days after your application for a

license is denied.

DOCUMENTS

REQUIRED FOR

EXAM

APPLICANTS

1. Proof of Education: Submit proof of education.

DOCUMENTS

REQUIRED FOR

EXAM WAIVER

APPLICANTS

License Verification: Have the licensing authority of each state/territory in which you hold or held a license at

any time, complete the "Verification of License" form and send it directly to the Board. Make copies of this

form, as needed. Check with the licensing authority (fees) for any fees you may need to pay and also the

length of time for that agency to process your license verification to our State.

Proof of Education: Submit proof of education.

NPTE Score Report: Request the Federation of State Boards of Physical Therapy (FSBPT) Score Transfer Service

to forward your score directly to the Board. An application for the FSBPT Score Transfer Service can be made on

the Internet at the website below or by contacting them directly.

FSBPT Score Transfer Service Phone: 1-703-739-9420

124 West Street South, 3rd Floor Website: www.fsbpt.net/pt

Alexandria, VA 22314 Email: scoretransfer@fsbpt.org

APPLICANTS

WITH SPECIAL

NEEDS

If you are requesting special testing arrangements due to a disability, call (808) 586-2711 immediately to obtain

a Disability Certification Form which must be completed by an approved professional, and submitted preferably

prior to your exam application, but no later than the exam filing deadline. Determination of qualification for

special testing arrangements will then be made and if so, the type of special testing arrangements to be provided.

No action will be taken to provide special testing arrangements until your exam application has been approved.

(CONTINUED ON PAGE 6)

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FEES (cont'd)

Mail to: Deliver to Office Location:SUBMITTING

APPLICATION

Board of Physical Therapy

DCCA, PVL Licensing Branch

P.O. Box 3469

Honolulu, HI 96801

335 Merchant Street, Room 301

Honolulu, HI 96813

Phone: (808) 586-3000

Toll free voice access numbers for the neighbor islands:

Kauai - 274-3141 ext. 6-3000 Molokai - 1-800-468-4644 ext. 6-3000

Maui - 984-2400 ext. 6-3000 Lanai - 1-800-468-4644 ext. 6-3000

Hawaii - 974-4000 ext. 6-3000

Instructions for "YES" Answers to Questions (5) through (7) of the Application for License (PT-01)

A. The following documentation must be submitted with the license application. Applications for license will not be considered

without this material.

Questions 5 and 6 refer to complaints, charges of unlicensed activity, or pending disciplinary actions for any profession,

occupation, or license. If your answer is "Yes" to one or more of these questions, read paragraph "B" below, AND you must

submit the following:

i. A statement signed by you explaining the circumstances; and

ii. Copies of any documents from the agency, including final orders, petitions, complaints, findings of fact and conclusions

of law, and any other relevant documents;

2. If your application indicates a criminal conviction, read paragraph "B" below, and you must submit the following:

i. A statement signed by you explaining the circumstances leading to the conviction and detailing all activities since the

conviction, including employment and business involvements. Include job title, period of employment, employer's name,

description of duties, training attended, and educational courses attended.

ii. A copy of the court order, verdict, and terms of sentence; and

iii. If applicable, a copy of the terms of probation and/or parole and a notarized statement from your probation or parole

officer as to your compliance with the court orders;

iv. A current criminal history record check in your name from the state where the conviction occurred and the state where you

currently reside, if different. In Hawaii, you may obtain a criminal history record check from the Hawaii Criminal Justice Data

Center. Contact the Department of the Attorney General, Hawaii Criminal Justice Data Center, Kekuanao'a Building, 456 S.

King Street, Room 102, Honolulu, Hawaii 96813. Ph: (808) 587-3279 or visit their website at: ag.hawaii.gov/hcjdc. For other

states/jurisdictions, contact the local authority or Board for their forms, instructions and fees on obtaining a criminal history

record check.

BIENNIAL

RENEWAL

All licenses, regardless of issuance date, expire on December 31 of each EVEN NUMBERED year. The licensee is

held responsible to keep his/her license current. If you let your license lapse for longer than one year, you must file

a new application and meet requirements that are in effect at the time of filing.

-6-

B. If you answered "Yes" to any of the questions (5) through (7), your application may be reviewed at a Physical Therapy Board meeting

if you have provided all applicable information and documents as described above. The Board will not review incomplete

applications. If you wish to present oral testimony at the meeting, submit a written request with your application.

LAWS & RULES The licensee is held accountable for knowing and complying with the Hawaii laws and rules of physical therapy

practice as failure to comply may result in disciplinary action. Obtain copies of the physical therapy laws, Chapter 461,

Hawaii Revised Statutes and rules, Chapter 110, Hawaii Administrative Rules by sending a written request to the

Board's address above. Chapter 436B, Hawaii Revised Statutes, the Professional and Vocational Licensing Act should

be read in conjunction with the above statutes.

The laws and rules are also posted on our website at: cca.hawaii.gov/pvl. Click on "Physical Therapy".

Pursuant to §16-110-10(d), Hawaii Administrative Rules, your application shall be considered abandoned and shall

be destroyed if a license is not issued within one year of the application date as a result of:

ABANDONMENT

OF APPLICATION

failure to complete licensure requirements, or (1)

take the required licensure examination, if required, or(2)

to submit the required documentation and evidence of qualifications.(3)

If the application is deemed abandoned, the applicant shall submit a new application form, documentation of

qualifications, and applicable fees in addition to meeting licensure requirements that are in effect at the time of

filing the new application.

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

Print Form

Application for License - PHYSICAL THERAPIST

Access this form via website at: cca.hawaii.gov/pvl

Read the Information/Requirements and Instructions before completing this form.

Effective Date

PT -

License No.

FOR BOARD USE ONLY

Temporary License Effective:

Applying for:

(state)

(state/country) on (date(s))

on (date)

Legal Name of Applicant (First, Middle) (Last)

Residence Address (Include Apt. No., City, State & Zip Code)

Mailing Address (ONLY if different from residence) Other Names Used (Include Maiden Name)Date of Birth

Phone No. (Days)

Check your answers. If response is "Yes" to questions 5 to 7, refer to the instructions for additional documents that must be submitted with

this application.

1) Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2) Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

3) Do you now hold or have you ever held a physical therapist license in another state or territory? . . . . . . . . . . . . . . . . . . . . . . . .

If "YES", list below.

Yes No

4) Have you ever held a license in Hawaii?

Appl . . . . . . . . . . . . . . . 513 . . . . . . . . . . . . . . . . $50 1/2 Renewal . . . . . . . . 510 . . . . . . . . . . . . . . . . $65

Lic . . . . . . . . . . . . . . . . . 516 . . . . . . . . . . . . . . . . $85 Temp . . . . . . . . . . . . . . 517 . . . . . . . . . . . . . . . . $50

CRF . . . . . . . . . . . . . . . . 518 . . . . . . . . . . . . . . . . $50/$100 Service Charge . . . . . BCF . . . . . . . . . . . . . . . . $25

PT-01 0519R

(CONTINUED ON PAGE 2)

Lic. No.: Exp. Date:

. . . . . . . . .

Yes No

5) Has any license ever been suspended, revoked or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

6) Are there any disciplinary actions pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

7) Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . . . . . . Yes No

EDUCATIONSTATE LICENSES

Name of College/University Location (City/State)

Dates (mo/yr)

From To

Degree Earned

Name of State

(Attach additional sheets if needed)

ORIGINAL state

License No. Date Issued

Provide date

Verification was

Requested

Method of Licensure

National

Exam

State

Exam

Waived

License Current?

YES NO

***SIGNATURE REQUIRED ON NEXT PAGE***

Temporary license. Attach separate fee of $50.

Exam, failed exam in

Exam, first time.

License by exam waiver: Passed national PT exam in

Social Security No.

Approved

Initials/Date:

Affidavit of Applicant:

I hereby certify that the statements, answers and representations made in this application and the attached documents are true and correct.

I understand that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Section 710-1017,

Sections 436B-19 and 461J-12, Hawaii Revised Statutes). I further certify that I have read, understand and will obey the laws and rules concerning

physical therapy in the State of Hawaii.

Print Name of Applicant: Date:

Signature of Applicant Date

APPLICATION FOR PHYSICAL THERAPY

Release of Information to Third Party:

To assist me in the licensing process, I authorize the Board of Physical Therapy and staff to release any and all information regarding my

application (including but not limited to, application status) to:

Print Name of Individual who is assisting you:

Signature of Applicant Date

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit

your request.

-2-

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