Revised 12.30.21
____ a.
APPLICATION:
Properly completed, signed and notarized application, including Applicant Responsibility statement;
Recent passport quality photograph (at least 2”x 2”) attached to application;
Appropriate explanations and copies of all pertinent documentation must be attached for affirmative responses to questions
numbered 8, 9, 10, 11, 12, 12a, 13, 20, 21, 22, 23, 24, and 25;
Release form - signed and notarized (Form A);
____ b.
FEES:
Proper application, registration, AND criminal background investigation fees – cashier’s check or money order made payable to
Nevada State Board of Medical Examiners (NSBME) or by credit card as instructed. Credit cards will only be accepted by receipt
of the signed credit card authorization form. Note: Application and criminal background investigation fees are non-refundable;
____ c.
IDENTITY (Important identity documents will be returned to you via secured mail):
1. U.S. born citizens – Original or Certified Birth Certificate that bears an original seal or stamp of the issuing agency (notarized
copies are not acceptable);
2. Foreign-born citizens - Original Certificate of Naturalization or current U.S. Passport;
3a. Non-U.S. citizens (with legal status):
Copy of both sides of Alien Registration or Employment Authorization card, or Visa; and
Copy of foreign passport.
3b. Non-U.S. citizens (otherwise):
Individual Taxpayer Identification Number (ITIN) and original ITIN assignment letter from the IRS
Supporting documentation of identity also required, e.g., Passport, or USCIS, US Military, or
US State I.D.
Note: FCVS verification packet may provide appropriate “Seal verified” Identity documentation.
____ d.
SELF-QUERY VERIFICATION:
Self-query response from the National Practitioner Data Bank (NPDB); The NPDB will send the report directly to you and you
will forward the final report to the Board office;
The request form for the National Practitioner Data Bank (NPDB) is available at http://www.npdb.hrsa.gov. Click on ‘Self-Query’
for Healthcare Professionals on the right side of the page and follow the instructions provided. If you require additional information,
please call the NPDB at (800) 767-6732. Once you have received the final report or self-query response from the NPDB, forward a
copy of this report to the Board office.
____ e.
SUPPLEMENTARY FORM:
FORM B: ONLY if you have answered affirmatively to either of the two malpractice questions on the application; Also
include:
o Copy of the legal Complaint
o Copy of the Settlement and/or filed Dismissal
____ f.
EDUCATION:
Copy of high school transcripts or diploma;
Copy of transcripts or diplomas for degrees other than Physician Assistant degree – an Associates, Bachelors or Masters
Degree that you would like added to your educational profile on the Board’s website;
____ g.
NOTIFICATION OF SUPERVISION
Notification for supervision of Physician Assistant to Nevada State Board of Medical Examiners (signed and notarized);
Please note: If you do not yet have a supervising physician who is a Nevada licensed Medical Doctor, you can obtain licensure;
however you cannot practice in the state of Nevada until such time as you have a supervising physician agreement (Notification for
Supervision of a Physician Assistant) approved by the Board.
____ h.
CONTINUING EDUCATION:
Proof of 4 hours bioterrorism AMA Category 1 continuing medical education (CME) relating to the medical consequences of an
act of terrorism that involves the use of a weapon of mass destruction. Search for an online course by entering “AMA Category
1 bioterrorism continuing medical education” or take a classroom course;
Proof of 2 hours AMA Category 1 continuing medical education (CME) in clinically-based suicide prevention and awareness;
Proof of 2 hours AMA Category 1 continuing medical education (CME) in the screening, brief intervention and referral to
treatment approach to substance use disorder.
____ j.
FINGERPRINTING:
Once the application and criminal background investigation fee have been received, a fingerprint card and instructions will be
mailed to you. The fingerprint card you receive from the Board contains the necessary account numbers required for processing.
The completed card must be returned to the Board as well as the signed Civil Applicant Waiver (included in your application
package) prior to licensure. Note: Receipt of the Criminal history background results will not delay licensure.
PHYSICIAN ASSISTANT
APPLICATION CHECKLIST
TO BE RETURNED DIRECTLY TO BOARD OFFICE BY APPLICANT
