Preceptor Application and Letter of Intent (1) (1)

PRECEPTOR APPLICATION

PLEASE TYPE OR PRINT CLEARLY

SECTION A

Preceptor Name :

(Last)

(First)

(MI)

(Suffix)

(Degree)

Advanced Practice Provider’s Collaborating Physician :

Facility/Practice Name:

Preceptor Mailing Address:

(Street)

(City)

(State)

(Zip Code)

(County)

Phone Number:

Fax Number:

Email Address:

Office Manager Name:

Office Manager Phone Number:

Office Manager Email Address:

☐ I have included a copy of my CV, state licensure, and board certification with this application ☐ I will email a copy of my CV, state licensure, and board certification ASAP SECTION B Practice Type – Please check all that apply (B3.0 1) ☐ Hospital Clinic ☐ Non - Profit Health Clinic ☐ Private Group Practice ☐ Public Health Clinic ☐ Rural Health Clinic ☐ Private Solo Practice ☐ Surgery Center/OR ☐ Hospital/Health System ☐ Telehealth ☐ Military ☐ Inpatient ☐ Outpatient

Practice Specialty – Please check all that apply (B3.06) ☐ Family Medicine ☐

Emergency Medicine Behavioral Health

☐ Internal Medicine

☐ ☐ ☐

☐ Pediatrics ☐ Surgery

Women’s Health

Elective:

Please email this completed form to Dr. Robert Hill (rhill25@nl.edu) or Mr. Ryan Atkins (ratkins3@nl.edu).

The National Lous University (NLU) Physician Assistant Program will apply for Accreditation - Provisional from the Accreditation Review Commission on Education for the Physician Assistant (ARC - PA). The NLU Physician Assistant Program anticipates matriculating its first class in September of 2027, pending achievement of Accreditation - Provisional status at the June of 2027 ARC - PA meeting. Accreditation - Provisional is an accreditation status granted when the plans and resource allocation, if fully implemented as planned, of a proposed program that has not yet enrolled students appear to demonstrate the program’s ability to meet the ARC - PA Standards or when a program holding accreditation - provisional status appears to demonstrate continued progress in complying with the Standards as it prepares for the graduation of the first class (cohort) of students.