Request for PAPR
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Last Name
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First Name
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MI
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Address
Address
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City
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State
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Zip
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Phone
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E-mail
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Name of PA school from which you graduated
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Month and year of graduation
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Date of birth (mm/dd/yyyy)
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Most of my time as a PA is spent in the following setting (select one)
HMO
Solo Practice Physician's office
Group Practice Physicians' office
Hospital
Other free-standing clinic
Federally qualified health center - rural
Federally qualified health center - not rural
Other
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Primary specialty (select one)
Addiction Medicine
Allergy
Anesthesiology
Dermatology
Emergency Medicine
Family Practice w/o Urgent Care
Family Practice wt Urgent Care
Genetics
Geriatrics
Obstetrics/Gynecology
Occupational Medicine
Ophthalmology
Pain Management
Pathology
Physical Med Rehab
Psychiatry
Public Health
Radiation Oncology
Radiology
Surgery - General Surgery
Surg: Cardiovacular/Cardiothoracic
Surg: Colon & Rectal
Surg: Hand
Surg: Neurology
Surg: Oncology
Surg: Ortopedics
Surg: Otorhinolaryngology
Surg: Pediatric
Surg: Plastic
Surg: Thoracic
Surg: Transplant
Surg: Trauma
Surg: Urology
Surg: Vascular
Surg: Other
Pediatrics - General Pediatrics
Ped: Adolescent Medicine
Ped: Allergy
Ped: Cardiology
Ped: Critical Care
Ped: Endocrinology
Ped: Gastroenterology
Ped: Hematology/Oncology
Ped: Infectious Disease
Ped: Neonatal-Perinatal
Ped: Nephrology
Ped: Neurology
Ped: Pulmonology
Ped: Rheumatology
Ped: Other
Internal Medicine - General Internal Medicine
IM: Cardiology
IM:Critical Care
IM: Endocrinology
IM: Gastroenterology
IM: Hematology/Oncology
IM: Immunology
IM: Infectious Disease
IM: Nephrology
IM: Neurology
IM: Pulmonology
IM: Rheumatology
IM: Other
Other
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As a PA, I am working (select one)
Full-time
Part-time
Not in clinical practice as a PA
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