Send a form within 30 days of beginning employment or any change in your supervising physician or work setting.
Notify the Board of Registration of Physician Assistants of all information related to your supervising physician.
- This page, Report a change or addition in supervising physician or work setting, is offered by
- Board of Registration of Physician Assistants
- Bureau of Health Professions Licensure
- Department of Public Health
Report a change or addition in supervising physician or work setting
Contacts
Board of Registration of Physician Assistants
Phone
The Details of Report a change or addition in supervising physician or work setting
What you need for Report a change or addition in supervising physician or work setting
Notify the Board all information related to your supervising physician and work setting if you are a licensed Physician Assistant or temporary certificate holder in Massachusetts.
You may complete a report form to:
- Add an initial or additional supervising physician
- Replace your current supervising physician
- Terminate a supervising physician
- Change your work setting information
How to report Report a change or addition in supervising physician or work setting
Mail your completed and signed Supervising Physician and Work Setting Information Form to:
MA Board of Registration of Physician Assistants
250 Washington Street
Boston, MA 02108
Please keep a copy for your records.
Downloads for Report a change or addition in supervising physician or work setting
Open PDF file, 43.28 KB,
Supervising Physician and Work Setting Information Form
(English, PDF 43.28 KB)
Open DOC file, 85.5 KB,
Supervising Physician and Work Setting Information Form
(English, DOC 85.5 KB)
Contact for Report a change or addition in supervising physician or work setting
Address
250 Washington Street, Boston, MA 02108
Phone
Fax
(617) 973-0980