Physician Assistant (PA)- Healthcare Practitioner Licensing 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Health Care Provider section. Enter your name, institution, license number, specialization, and contact details accurately.
3. Provide a written diagnosis along with the relevant ICD-9CM and/or DSM codes in the designated field.
4. Indicate how long you have been treating the patient and when you last saw them. This information is crucial for assessing their current condition.
5. Specify the expected duration of the disability by selecting either 'Short Term' or 'Long Term' based on your assessment.
6. Answer whether the applicant’s disabilities prevent them from using accessible transit independently. If yes, provide detailed explanations in the following fields.
7. Complete questions regarding mobility aids required by the applicant and any medications that may affect their ability to travel.
8. Finally, ensure all sections are filled out completely before signing and dating the certification at the end of the form.

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