Preceptor Application

University Home > Academic Paths > Graduate Degrees > Master of Science in Physician Assistant > Physician Assistant Program Department > Preceptor Application

Thank you for your interest in becoming a Preceptor! Please complete the online application below or download form and submit as directed.

Name*
First Last
Title*
Specialty
Medical Board License Number*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone*
Cell Phone
Fax
Email*
Office Manager (or person to contact when scheduling a student)
Office Manager Phone
Office Manager Email
Preferences
How many PA students are you willing to precept each year (12 months) for:
Family Medicine
General Surgery
Pediatrics
Psychiatry/Behavioral Health
OB/GYN
Emergency Medicine
Internal Medicine (inpatient)
Internal Medicine (outpatient)
Other
Credentialing
Please list all facilities that students will need to be credentialed.
Facility % of cases Facility Contact Name for Credentials Contact Number
About Your Practice
Do you have any colleagues working with you that may be participating in the precepting of our students? If yes, please provide their name(s) and whether MD, DO, PA, or NP:
Name Title
Does your practice maintain professional liability insurance?*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Contact Us

PA Program
Maria Sanchez
Phone: (509) 865-0707
Email:
pa_hu@heritage.edu

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