Physical Therapy Form 5 "Application for Limited Permit" - New York

What Is Physical Therapy Form 5?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Physical Therapy Form 5 by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Physical Therapy Form 5 "Application for Limited Permit" - New York

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The University of the State of New York
Department Use Only
Physical Therapy Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Application for Limited Permit
APPLICANT INSTRUCTIONS
1.
You may file an application for a limited permit with or after submitting an Application for
Licensure (Form 1) and fee as a physical therapist or physical therapist assistant in New
York State to practice pending receipt of the license. A limited permit authorized practice
under the supervision of a New York State licensed, currently registered, physical therapist. When
applying for a limited permit, it is your responsibility to ensure that your prospective employer fully
completes Section II, Certification of Supervision.
2.
Complete Section I in ink. Be sure to sign and date item 8. Note: once limited permits are issued,
they may not be adjusted. You should be certain you are ready to begin practice when you apply
NYS Permit Number
for the limited permit.
3.
Submit this application and a $70 fee for physical therapist, $50 for physical therapist assistant, to
the address at the end of this form. If you have not yet filed an Application for Licensure (Form 1)
Initials
and a fee of $294 for physical therapist, $103 for physical therapist assistant, you must submit
them with this form and the limited permit fee. Your permit cannot be issued until we receive
and approve all required documentation. You may not begin practice until your limited permit is
Date Issued
issued. (Physical therapist applicants: see explanation of exemption in Section II:
Certification of Supervision). The limited permit fee is not refundable.
4.
If you change employment after a permit is issued, you must obtain a new permit and, with each
Date Expires
prospective employer, complete a new Form 5 and return it to the Office of the Professions. A new
fee is not required for a permit issued as a result of a change in employment. A limited permit may
6
be renewed for one additional 6 month period with the appropriate fee.
Telephone/E-Mail Address
1
Check which profession you are applying for:
Daytime Phone
62
$70
PR
Physical Therapist
66
$50
PR
Physical Therapist Assistant
Area Code
Phone Number
E-Mail Address (Please print clearly)
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
3
Month
Birth Date
Day
Year
4
Print Your Name Exactly As It Appears On Your Licensure Application
7
I Am Applying For:
Last
Original Permit
First
Renewal of Permit
Middle
Change in:
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Employer
Line 1
Supervisor
Line 2
Additional:
Line 3
Employer
Supervisor
City
State
Zip Code
6 Month Extension
Country/
Province
8
ATTESTATION
NOTICE TO PHYSICAL THERAPIST/PHYSICAL THERAPIST ASSISTANT APPLICANTS
REGARDING LIMITED PERMIT PRACTICE RESTRICTIONS
The law authorizes a permittee to practice under the supervision of a New York State licensed and currently registered physical therapist in a public
hospital, an incorporated hospital or clinic, a licensed proprietary hospital, a licensed nursing home, a public health agency, a recognized
public or non-public school setting, the office of a licensed physical therapist, or in the civil service of the state or political subdivision
thereof. As a permittee, you may not practice under the supervision of a physician.
I declare and affirm that the statements made in the foregoing application are true complete and correct. Any false or misleading information in, or in
connection with, my application may be cause for denial of permit and licensure and may result in criminal prosecution.
Applicant’s Signature
Date
Physical Therapy Form 5, Page 1 of 2, Rev. 1/12
The University of the State of New York
Department Use Only
Physical Therapy Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Application for Limited Permit
APPLICANT INSTRUCTIONS
1.
You may file an application for a limited permit with or after submitting an Application for
Licensure (Form 1) and fee as a physical therapist or physical therapist assistant in New
York State to practice pending receipt of the license. A limited permit authorized practice
under the supervision of a New York State licensed, currently registered, physical therapist. When
applying for a limited permit, it is your responsibility to ensure that your prospective employer fully
completes Section II, Certification of Supervision.
2.
Complete Section I in ink. Be sure to sign and date item 8. Note: once limited permits are issued,
they may not be adjusted. You should be certain you are ready to begin practice when you apply
NYS Permit Number
for the limited permit.
3.
Submit this application and a $70 fee for physical therapist, $50 for physical therapist assistant, to
the address at the end of this form. If you have not yet filed an Application for Licensure (Form 1)
Initials
and a fee of $294 for physical therapist, $103 for physical therapist assistant, you must submit
them with this form and the limited permit fee. Your permit cannot be issued until we receive
and approve all required documentation. You may not begin practice until your limited permit is
Date Issued
issued. (Physical therapist applicants: see explanation of exemption in Section II:
Certification of Supervision). The limited permit fee is not refundable.
4.
If you change employment after a permit is issued, you must obtain a new permit and, with each
Date Expires
prospective employer, complete a new Form 5 and return it to the Office of the Professions. A new
fee is not required for a permit issued as a result of a change in employment. A limited permit may
6
be renewed for one additional 6 month period with the appropriate fee.
Telephone/E-Mail Address
1
Check which profession you are applying for:
Daytime Phone
62
$70
PR
Physical Therapist
66
$50
PR
Physical Therapist Assistant
Area Code
Phone Number
E-Mail Address (Please print clearly)
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
3
Month
Birth Date
Day
Year
4
Print Your Name Exactly As It Appears On Your Licensure Application
7
I Am Applying For:
Last
Original Permit
First
Renewal of Permit
Middle
Change in:
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Employer
Line 1
Supervisor
Line 2
Additional:
Line 3
Employer
Supervisor
City
State
Zip Code
6 Month Extension
Country/
Province
8
ATTESTATION
NOTICE TO PHYSICAL THERAPIST/PHYSICAL THERAPIST ASSISTANT APPLICANTS
REGARDING LIMITED PERMIT PRACTICE RESTRICTIONS
The law authorizes a permittee to practice under the supervision of a New York State licensed and currently registered physical therapist in a public
hospital, an incorporated hospital or clinic, a licensed proprietary hospital, a licensed nursing home, a public health agency, a recognized
public or non-public school setting, the office of a licensed physical therapist, or in the civil service of the state or political subdivision
thereof. As a permittee, you may not practice under the supervision of a physician.
I declare and affirm that the statements made in the foregoing application are true complete and correct. Any false or misleading information in, or in
connection with, my application may be cause for denial of permit and licensure and may result in criminal prosecution.
Applicant’s Signature
Date
Physical Therapy Form 5, Page 1 of 2, Rev. 1/12
SECTION II: CERTIFICATION OF SUPERVISION
INSTRUCTION TO THE EMPLOYER/SUPERVISOR
Sections 6735 (c) and 6741-a(b) of the Education Law require all practice under a limited permit to be under the on-site supervision of a
licensed physical therapist in a public hospital, an incorporated hospital or clinic, a licensed proprietary hospital, a licensed nursing
home, a public health agency, a recognized public or non-public school setting, the office of a licensed physical therapist or in the civil
service of the State or political subdivision thereof.
1. By completing the information below, the employer is certifying that the permittee named in Section I will be supervised by a licensed
physical therapist who is registered in New York State and that the employer agrees to abide by the conditions stipulated on the
permit.
2. The applicant may not begin practice until the limited permit is issued.
3. A limited permit expires six months from the date of issuance.
4. For Physical Therapist applicants only: Section 6736 (b)(2) of the Education Law, which allows a physical therapist graduate of
an approved program to practice under the on-site supervision of a licensed physical therapist provided that the graduate has: (a)
applied and paid the required licensure application fee and the fee for the licensing examination, and (b) applied and paid a fee for
the limited permit. This exemption shall not extend beyond 90 days after graduation.
A physical therapist serving as the supervisor may not concurrently supervise more than four (4) permittees.
5.
Name of facility:
Street address:
City:
State:
Zip code:
Telephone:
Fax:
E-mail:
The above facility is a: (check one)
Public hospital
Licensed proprietary hospital
Recognized public or non-public school setting
Office of a licensed physical therapist
Public health agency
Licensed nursing home
Incorporated hospital or clinic
ATTESTATION
In accordance with Section II above, I declare that the statements made in Section III are true, complete and correct. Any false or
misleading information in, or in connection with this certification, may be cause for disciplinary action against my license and may
result in criminal prosecution.
I certify that the physical therapist/physical therapist assistant limited permit applicant named in this application is being hired to
practice at the facility named above and that I am supervising no more then four (4) permittees.
Name of supervising physical therapist
(please print):
Signature of supervising physical therapist: _________________________________________ Date:
/
/
mo.
day
yr.
N.Y.S. license number of supervising physical therapist:
Telephone:
Fax:
E-mail:
Note: A limited permit must be reissued if the permittee’s practice site should change or to reflect a change in the
supervising physical therapist. A new fee is not required.
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,
NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Physical Therapy Form 5, Page 2 of 2, Rev. 1/12
Page of 2