Physician Assistant Applications and Forms
To practice in West Virginia all physician assistants must hold an active status license or registration issued by the Board and have either:
- A Practice Agreement authorized by the Board prior to July 8, 2021
- An activated Practice Notification.
APPLY FOR LICENSURE
To apply for an initial physician assistant license or reactivate a license that has been expired for more than one year, please complete the Physician Assistant Licensure Application.
All initial licensure applicants must also complete a Criminal History Record Check.
To apply for reinstatement of a physician assistant license which expired on March 31, 2021, please complete the Physician Assistant Reinstatement Application. The Physician Assistant Reinstatement Application is valid until March 31, 2022.
PHYSICIAN ASSISTANT PRACTICE
Effective July 8, 2021, the Board no longer accepts Practice Agreements. Practice Agreements authorized prior to July 8, 2021 are still valid, and PAs who currently are practicing in collaboration with a physician pursuant to a practice agreement may continue to do so until it terminates or until June 1, 2022, whichever is sooner. Hospital Practice Notifications issued prior to July 8, 2021 are not effected by these changes.
The Practice Notification form with instructions is available below and replaces all other forms previously utilized for PA practice. A Practice Notification must be completed and signed by both the PA and a representative of the health care facility where the physician assistant seeks to practice. The form must also be accompanied by the $100 nonrefundable Practice Notification fee. PAs must receive notification from the Board that the Practice Notification has been activated prior to commencing practice.
PAs with an active Practice Notification may perform medical acts and procedures in collaboration with physicians which are commensurate with their education, training and experience, the collaborating physician’s scope of practice, and any credentialing requirements of the health care facility with which they have an active Practice Notification.
Information related to a PA’s currently authorized Practice Agreement(s) and/or activated Practice Notification(s) is available for review on the PA’s licensee profile which may be accessed through the Look Up a Doctor or PA search feature on the Board’s website. Emergency registrant authorizations/activations to practice are listed on the COVID-19 Emergency Registrations page
Please review the Physician Assistant Practice Act.
PRACTICE NOTIFICATION FORMS (Revised April 2022)
Practice Notification and Instructions
Practice Notification Form A
Notification of Termination of a Practice Agreement or Notification
Controlled Substance Dispensing Practitioner Registration Form for Physicians, Podiatric Physicians and Physician Assistants
Charitable Exemption Authorization for WVBOM licensees
Charitable Exemption Authorization for PAs licensed in Other States
Name Change Affidavit
Duplicate Wall License Request
If you have any questions you may contact the Board’s Physician Assistant Licensure Analyst at (304) 558-2921, ext. 49873.