[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-277730-105":3,"detail-sidebar-cat-1-en-105":73,"doc-detail-277730-en":119},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":66,"head_meta":68,"extra_data":70,"updated_unix":72},105,"en","application-to-supervise-a-physician-assistant-physician-assistant-advisory-committee-supervision-levels","Application to Supervise a Physician Assistant - Physician Assistant Advisory Committee Supervision Levels","","Application to Supervise a Physician Assistant for the Kentucky Board of Medical Licensure includes instructions, required signatures, and fillable fields for submission. It explains supplemental scope of practice requirements, supervising application fees and transfer fee rules, and consequences of incomplete forms. The document outlines how supervision must be designated using direct, on-site, and off-site supervision definitions, and provides payment and cardholder information sections. It also describes review by the Physician Assistant Advisory Committee and guidance for inquiries and temporary or tentative approval.",{"@graph":14,"@context":65},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/application-to-supervise-a-physician-assistant-physician-assistant-advisory-committee-supervision-levels/277730/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/application-to-supervise-a-physician-assistant-physician-assistant-advisory-committee-supervision-levels/277730.png","ImageObject",442,249,{"name":42,"@type":43},"Melati","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-15",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59],{"name":60,"@type":61,"acceptedAnswer":62},"What are the supervising physician application fees and transfer fee rules?","Question",{"text":63,"@type":64},"The supervising physician application fee is $100. If transferring supervision from a previously Board-approved physician to another physician within the same practice/group, the fee is $50.","Answer","https://schema.org",{"og:url":32,"og:type":67,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":69,"canonical":32},"index,follow",{"doc_id":71,"site_id":7},277730,1790238696,{"code":4,"msg":74,"data":75},"success",[76,81,86,91,96,101,105,110,115],{"id":77,"doc_module":22,"doc_module_name":25,"category_name":78,"show_sort_weight":79,"slug":80},11,"Presentations",90,"presentations",{"id":82,"doc_module":22,"doc_module_name":25,"category_name":83,"show_sort_weight":84,"slug":85},12,"Resumes",80,"resumes",{"id":87,"doc_module":22,"doc_module_name":25,"category_name":88,"show_sort_weight":89,"slug":90},14,"Invoices",70,"invoices",{"id":92,"doc_module":22,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},15,"Posters",60,"posters",{"id":97,"doc_module":22,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},16,"Social Media",50,"social-media",{"id":102,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":103,"slug":104},17,40,"forms",{"id":106,"doc_module":22,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},18,"Letters",30,"letters",{"id":111,"doc_module":22,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},21,"Paper Templates",5,"papers-templates",{"id":116,"doc_module":22,"doc_module_name":25,"category_name":117,"show_sort_weight":4,"slug":118},158,"General","general-158",{"code":4,"msg":74,"data":120},{"doc_id":71,"user_id":121,"nickname":42,"user_avatar":122,"doc_module":22,"category_id":102,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":123,"file_id":124,"file_url":125,"file_type":126,"file_size":127,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":77,"language":128,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":129,"faqs":130,"seo_title":131,"seo_description":12,"update_tm":132,"read_time":33},962085570644,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Kentucky Board of Medical Licensure  \n310 Whittington Parkway, Suite 1B  \nLouisville, KY 40222  \n[502/429-7150 www.kbml.ky.gov](502/429-7150 www.kbml.ky.gov)  \nApplication to Supervise a Physician Assistant  \nKEEP THIS PAGE FOR FUTURE REFERENCE  \nTHE SUPERVISING PHYSICIAN APPLICATION PDF CONTAINS FILLABLE FIELDS; HOWEVER, ORIGINAL SIGNATURES ARE REQUIRED. DO NOT SUBMIT HANDWRITTEN APPLICATIONS. The pdf can be located at: [http://www.kbml.ky.gov/ah/pa.htm](http://www.kbml.ky.gov/ah/pa.htm).  \n1. The Supplemental Application Scope of Practice of Physician Assistant (pages 6 & 7 of the Supervising Physician Application) is required to request additional scope of medical services and procedures only if the training has already been completed (see Examples sheet) .  \n2. The supervising physician application fee is $100 and must accompany the application. If you are TRANSFERRING supervision from a physician previously approved by the Board to supervise this physician assistant to another physician within the same practice/group, the fee is $50.  \n***INCOMPLETE APPLICATIONS WILL BE RETURNED. Retain a copy of the completed application for your records. Future requests for a copy of your application will necessitate an Open Records Request to the Board’s legal department.  \nThe Physician Assistant Advisory Committee meets quarterly to review applications and make recommendations to the Board for final approval (meeting dates can be located on the Physician Assistant page of the Board’s website) . Should you wish to begin employing the physician assistant prior to the Board meeting, there are provisions for temporary licensure for a new physician assistant applicant for Kentucky licensure; OR, tentative approval for supervising the physician assistant whose Kentucky license is active. Please note that temporary licensure or tentative approval must be granted prior to the physician assistant providing services under your supervision.  \nShould you have any questions regarding the above, please contact Mistee Joyce at (502) 764-2601.  \nDefinitions of Levels of Supervision  \nIt is necessary to indicate on the application the level(s) by which you will be supervising a physician assistant.  \nDirect Supervision: This means the supervising physician is actually in sight of the physician assistant when the physician assistant is performing the function requiring direct supervision. Although the physician may be performing some other task at the time, the supervising physician may immediately provide direction or assume the performance of the task if difficulties arise. This does not require that the physician is watching “over the shoulder” of the physician assistant as would be required during the training period to ensure that the physician assistant is competent to perform the task.  \nOn-site supervision: Requires the physical presence of the supervising physician in the same location (i.e. the physician’s office suite) as the physician assistant, but does not require the physical presence in the same room.  \nOff-site supervision: The supervising physician must be continuously available for direct communication with the physician assistant when the physician assistant is at a separate location than the practice address of the primary supervising physician by means of the line of communication specified by the primary supervising physician on his/her Application for Physician to Supervise Physician Assistant filed with the Kentucky Board of Medical Licensure.  \nKentucky Board of Medical Licensure  \n310 Whittington Parkway, Suite 1B  \nLouisville, Kentucky 40222  \nTelephone: (502) 429-7150  \n[www.kbml.ky.gov](www.kbml.ky.gov)  \nThe Supervising Application fee for the Supervising Physician Application is $100. You may pay the required fee by check, money order, or credit card. Make your check or money order payable to the Kentucky Board of Medical Licensure or KBML. Payment must accompany the submission of the application.  \nPlease complete the ","cbCaicQMrfTqkctP","https://ap.wps.com/l/cbCaicQMrfTqkctP","pdf",353029,"English","# Application to Supervise a Physician Assistant\n## Requirements and submission notes\n## Fees and payment information\n## Definitions of Levels of Supervision\n### Direct Supervision\n### On-site supervision\n### Off-site supervision\n## Contact and committee review","[{\"question\":\"What are the supervising physician application fees and transfer fee rules?\",\"answer\":\"The supervising physician application fee is $100. If transferring supervision from a previously Board-approved physician to another physician within the same practice/group, the fee is $50.\"}]","Application to Supervise a Physician Assistant - Physician Assistant Advisory Committee Supervision Levels | PDF",1789503439]