21 NCAC 32S .0221. LIMITED VOLUNTEER LICENSE

(a)  A physician assistant who holds a regular license in North Carolina may convert that license to a Limited Volunteer License by notifying the Board in writing.

(b) The Board may issue a Limited Volunteer License to a physician assistant who holds an active license or registration in another state.  In order to obtain a Limited Volunteer License, an applicant shall;

(1)           submit a completed application, attesting under oath that the information on the application is true and complete, and authorizing the release to the Board of all information pertaining to the application;

(2)           submit a recent photograph, at least two inches by two inches, affixed to the oath, and attested by a notary public;

(3)           submit documentation of a legal name change, if applicable;

(4)           supply a certified copy of applicant's birth certificate if the applicant was born in the United States or a certified copy of a valid and unexpired U.S. passport.  If the applicant does not possess proof of U.S. citizenship, the applicant must provide information about applicant's immigration and work status which the Board will use to verify applicant's ability to work lawfully in the United States;

(5)           submit proof of active licensure from another state or jurisdiction indicating the status of the license and whether or not any action has been taken against it;

(6)           submit two completed fingerprint record cards supplied by the Board;

(7)           submit a signed consent form allowing a search of local, state and national files for any criminal record;

(8)           pay a non-refundable fee to cover the cost of a criminal background check;

(9)           submit a FSMB Board Action Data Bank report;

(10)         submit a NPDB/HIPDB report, dated within 60 days of submission of the application;

(11)         submit documentation of CME obtained in the last three years;

(12)         upon request, supply any additional information the Board deems necessary to evaluate the applicant’s competence and character.

(c)  All materials must be submitted to the Board from the primary source, when possible.

(d)  An applicant may be required to appear in person for an interview with the Board or its agent to evaluate the applicant's competence and character.

(e)  An application must be completed within one year of the date of submission.

 

History Note:        Authority G.S. 90-9.3; 90-18(c)(13); 90-18.1;

Eff. December 1, 2012.