847-050-0021 Documents to be Submitted for Licensure The documents submitted must be legible and no larger than 8 ½” x 11”. All documents and photographs will be retained by the Board as a permanent part of the application file. If original documents are larger than 8 ½″ x 11″, the copies must be reduced to the correct size with all wording and signatures clearly shown. Official translations are required for documents issued in a foreign language. The following documents are required: (1) Application: Completed formal application provided by the Board. Required dates must include month, day, and year. (2) Birth Certificate: A copy of birth certificate and a copy of Change of Name documentation, Marriage Certificate, or Divorce Decree if the applicant’s name has been changed by court order, adoption, marriage, divorce, etc. (3) Photograph: A close-up, passport-quality photograph, front view, head and shoulders (not profile), with features distinct, taken within 90 days preceding the filing of the application. (4) Legible fingerprints as described in OAR 847-008-0068 for the purpose of a criminal records background check. (5) The results of a Practitioner Self-Query from the National Practitioner Data Bank. (6) The results of a Physician Data Center Query from the Federation of State Medical Boards. (7) The applicant must ensure the following required official documents are sent to the Board directly from: (a) The physician assistant or physician associate education program: (A) Proof of completion of a physician assistant or physician associate education program as specified in OAR 847-050-0020(1) and which includes degree issued, date of degree, dates of attendance, dates and reason of any leaves of absence or repeated years, and dates, name and location of education program if a transfer student. (B) A Verification of Education form; which must include information about an applicant’s knowledge base, clinical skills, medical judgement, professionalism, and ethics; including any concerns regarding possible impairment in the applicant’s ability to safely practice their profession. If the school is unable to complete the form or the Board determines that it is unacceptable, a copy of the transcripts may be acceptable. (b) Official Examination Certification: An official Examination Certification of the Physician Assistants National Certifying Examination (PANCE), showing the examination score, is required directly from the National Commission on Certification of Physician Assistants (NCCPA). (c) If requested by the Board, a letter verifying licensure in good standing from the state or states of all prior and current health-related licensure. Verification, sent directly from the boards, must show license number, date issued, examination grades if applicable and status. (d)(A) The Director or other official for practice and employment in hospitals, clinics, etc. in the United States and foreign countries: A currently dated original letter (a copy is not acceptable), sent directly from the hospital/clinic, must include a statement of good standing and specific beginning and ending dates of practice and employment, for the past five (5) years only. (B) If the applicant has ceased practice for more than two (2) years, employment verifications will be required for the past ten (10) years. (C) If such verification is unavailable or incomplete, provide three reference letters from physicians, physician assistants, or physician associates in the local medical community who are familiar with the applicant’s practice and who have known the applicant for more than six months. (8) Any other documentation or explanatory statements as required by the Board, including but not limited to medical records and criminal or civil records. Statutory/Other Authority: ORS 677.265 & ORS 677.512 Statutes/Other Implemented: ORS 677.512 History: OMB 17-2024, amend filed 10/10/2024, effective 10/10/2024 OMB 13-2024, amend filed 07/15/2024, effective 07/15/2024 OMB 4-2023, adopt filed 01/11/2023, effective 01/11/2023