Fill - Free fillable Information/Requirements INFORMATION/REQUIREMENTS AND INSTRUCTIONS FOR FILING

INFORMATION/REQUIREMENTS AND INSTRUCTIONS FOR FILING - OCCUPATIONAL THERAPIST LICENSE

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

Information/Requirements

WHO MUST

OBTAIN A

LICENSE

Any person who represents, advertises, or announces oneself, either publicly or privately, as an

occupational therapist, or uses in connection with the person's name or place of business the words

"occupational therapist licensed", "registered occupational therapist", "licensed occupational therapist",

"occupational therapist", or "doctor of occupational therapy", or the letters "OT", "OTh", "OTD", "OT/L",

"OTR/L", or "OTD/L", or any other words, letters, abbreviations, or insignia indicating or implying that the

person is an occupational therapist.

Filing Instructions

APPLICATION

FORM

Complete the online application form or print legibly in black ink. Sign the form and submit the

required documents and fees. Incomplete applications, including non-submission of the required

documents and fees will not be processed.

BUSINESS

ADDRESS

On the application, provide your business (or employer) name and complete address. If you are not

employed, state "Not Employed" and report this information within 30 days of the effective date of the

license.

SOCIAL

SECURITY

NUMBER

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

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.

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).

OC-01 0920R

(CONTINUED ON PAGE 2)

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

DOCUMENTS FOR

LICENSURE

Submit an original verification of certification (no photocopies please) issued by the National Board for

Certification in Occupational Therapy (NBCOT) showing that your certification is current and sent directly

to the Hawaii Occupational Therapy Program. (See below for NBCOT information).

NOTE; A copy of your NBCOT certificate and/or pocket card is not acceptable.

An electronic NBCOT verification is acceptable. Applicants are responsible for ordering a verification of

certification from the NBCOT website at:

https://www.nbcot.org/en/Certificants/Services#VerificationofCertification. You will have to log in to your

MyNBCOT account and order the verification of certification under Services.

NBCOT contact information:

National Board for Certification in Occupational Therapy (NBCOT)

One Bank Street, Suite 300

Gaithersburg, MD 20878

Phone: (301) 990-7979

Website: www.nbcot.org

Email: info@nbcot.org

FEES Make check payable to: COMMERCE & CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a

U.S. financial institution.)

If license will be issued in an ODD-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . $279

(Application Fee - $50* + License Fee - $86 + Compliance Resolution Fund - $100 +

1/2 Renewal - $43)

If license will be issued in an EVEN-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . $186

(Application Fee - $50* + License Fee - $86 + Compliance Resolution Fund - $50)

*Application fee is not 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 shall 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 Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes.

Your written request for a hearing must be directed to the agency that denied your application, and must

be made within 60 days of notification that your application for a registration has been denied.

-2-

(CONTINUED ON PAGE 3)

SUBMITTING

APPLICATION

Mail all required items to:

Occupational Therapy

DCCA, PVL Licensing Branch

P.O. Box 3469

Honolulu, HI 96801

Deliver to office location at:

335 Merchant St., Room 301

Honolulu, HI 96813

Phone No.: (808) 586-3000

NOTIFICATION OF

CHANGE OF

EMPLOYER,

MAILING ADDRESS

AND RESIDENCE

ADDRESS

REQUIRED

Every occupational therapist shall notify the Department of any change in employment, mailing and

residence addresses within thirty (30) days of the change.

BIENNIAL

RENEWAL

All licenses, regardless of issuance date, expire on December 31 of each EVEN-NUMBERED year

and are subject to re-licensure. Although courtesy notices are sent to the last address of record,

about six weeks before expiration, the licensee is responsible for keeping their license current.

AGE OF MAJORITY

& AUTHORIZATION

TO WORK IN

THE U.S.

In addition to the NBCOT certification requirements, applicants shall be beyond the age of majority (18

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

United States. If you are not a U.S. citizen or U.S. national or alien authorized to work in the U.S., your

application may be denied.

-3-

Instructions for "YES" Answers to Questions (4) through (6) of the Application for License (OC-02)

(CONTINUED ON PAGE 4)

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

considered without this material.

Questions 4 and 5 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, you must submit the following:

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;

If your application indicates a criminal conviction, you must submit the following:

ii.

iii.

iv.

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.

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

A current criminal history record check in your name dated within six months of the date your application is

received 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

them at (808) 587-3100 or visit their website at: ecrim.ehawaii.gov to request a "Criminal History Record Check"

form;

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

as to your compliance with the court orders (terms and conditions imposed including any court documentation).

ABANDONMENT

OF APPLICATION

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you

fail to provide evidence of continued efforts to complete the licensing process for two consecutive years.

The failure to provide evidence of continued efforts includes but is not limited to: (1) failure to submit

any required information and documents requested by the licensing authority within two consecutive

years from the last date the documents and information were requested, or (2) failure to complete any

additional requirements for licensure that remain after approval of your application, such as attempting

to complete an exam requirement, within two consecutive years from the date your application was

approved, or (3) failure to provide the licensing authority with any written communication during two

consecutive years indicating that you are attempting to complete the licensing process. If an application

is deemed abandoned the applicant shall be required to reapply for licensure and comply with the

licensing requirements in effect at the time of the reapplication.

-4-

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.

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.

LAWS AND RULES The licensee is held accountable for knowing and complying with the Hawaii laws of occupational

therapy practice as failure to comply may result in disciplinary action. Obtain copies of the occupational

therapy laws, Chapter 457G, Hawaii Revised Statutes by sending a written request to: Occupational

Therapy, Commerce & Consumer Affairs, P.O. Box 3469, Honolulu, HI 96801. Chapter 436B, Hawaii

Revised Statutes, the Professional and Vocational Licensing Act should be read in conjunction with

Chapter 457G.

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

Therapy".

Print Form

APPLICATION FOR LICENSE - OCCUPATIONAL THERAPIST

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

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

READ INSTRUCTIONS BEFORE COMPLETING THIS FORM.

FOR OFFICE USE

Approval:

Initial/Date:

Effective Date: License No.

OT -

Legal Name (First, Middle) (Last)

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

Business (Employer) Name & Complete Address (If not employed, state "Not Employed". Report

this information within 30 days of effective date of license)

Mailing Address (If different from residence)

Other Names Used (Include Maiden Name) Social Security Number

Phone No. (days)

Check your answers. If response is "YES" to questions 4 to 6, refer to the instructions for additional documents that must be submitted with this

application.

Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

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

Do you hold or have you ever held an OCCUPATIONAL THERAPIST license/certificate/registration in

Hawaii and/or in another jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

Give name of jurisdiction and dates:

Has any license/certificate/registration ever been suspended, revoked or otherwise subject to disciplinary action? . . . . . Yes No

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

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

Affidavit of applicant:

I hereby certify that the statements, answers and representations made in this application and on the documents attached 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, and section 436B-19, Hawaii Revised Statutes). I further certify that I have read, understand and will obey the laws and rules

concerning occupational therapy in the State of Hawaii.

Signature of Applicant Date

OC-02 0920R

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.

1/2 Ren . . . . . . . . . . . . 727 . . . . . . . . . . . . . . . . $43

CRF . . . . . . . . . . . . . . . . 729 . . . . . . . . . . . . . . . . $50/$100

Service Charge . . . . . BCF . . . . . . . . . . . . . . . . $25

Date of Birth:

3a.

Release of Information to Third party:

To assist me in the licensing process, I hereby authorize DCCA's staff to release any and all information regarding my application

(including, but not limited to application status) to the following third party:

Print Name of Individual who is assisting you:

Signature of Applicant Date

CHECKLIST:

Business add or

"NOT EMPLOYED"

NBCOT

Verification

Name of Organization:

Appl . . . . . . . . . . . . . . . 720 . . . . . . . . . . . . . . . . $50

Lic . . . . . . . . . . . . . . . . . 723 . . . . . . . . . . . . . . . . $86

Print Form

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

InformationRequirements INFORMATIONREQUIREMENTS AND INSTRUCTIONS FOR FILING - OCCUPATIONAL (Hawaii)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Information/Requirements INFORMATION/REQUIREMENTS AND INSTRUCTIONS FOR FILING - OCCUPATIONAL (Hawaii) Form

Related forms

Fillable Information/Requirements INFORMATION/REQUIREMENTS AND INSTRUCTIONS FOR FILING - OCCUPATIONAL (Hawaii)

Fill Online, Printable, Fillable, Blank Information/Requirements INFORMATION/REQUIREMENTS AND INSTRUCTIONS FOR FILING - OCCUPATIONAL (Hawaii) Form

Related forms

First 20 documents completely FREE!