Application for Certification of a MOBILE OPTOMETRY CLINIC

  • pursuant to NRS 636 and NAC 636

    Please note: Each clinic must be licensed using this form. An optometrist providing services through the clinic will list the clinic as a practice location. No additional certification is required of the optometrist.

  • 1. “Medically underserved group” means a population that:

    (a) Has been designated as a medically underserved population by the United States Secretary of Health and Human Services pursuant to 42 U.S.C. § 254c; or
    (b) Resides in an area that has been designated as a health professional shortage area with a score of 13 or above by the United States Secretary of Health and Human Services pursuant to 42 U.S.C. § 254e.

    2. “Mobile optometry clinic” means an optometrist moving optometric instruments or equipment to a location, other than a building with fixed equipment and instruments maintained for practicing optometry under the conditions described in section 4 of Assembly Bill No. 77, chapter 568, Statutes of Nevada 2019, at page 3636. The term:

    (a) Includes, without limitation, a vehicle in which an optometrist provides optometric services.
    (b) Does not include an optometrist practicing in different buildings which each have fixed equipment and instruments maintained for practicing optometry or providing optometric services under conditions other than those described in section 4 of Assembly Bill No. 77, chapter 568, Statutes of Nevada 2019, at page 3636.
  • Select any one:

  • intend to own and/or operate a “mobile optometry clinic” as that term is defined in NRS 636 and NAC 636, and agree to limit the services, geographical regions and persons served by the mobile optometry clinic to those identified in NRS and NAC Chapters 636.

  • , intend to operate a “mobile optometry clinic” as that term is defined in NRS 636 and NAC 636, and agree to limit the activities, geographical regions and persons served by the mobile optometry clinic to those identified in NRS and NAC Chapters 636.

  • Select any that apply:

    • The clinic will utilize a vehicle into which patients will enter for eye examinations.

    • The clinic will travel to patients with the equipment needed for eye examinations, but will conduct such examinations in the facility convenient for the patients.
  • I recognize that I must keep a written log of each date and address where the mobile optometry clinic offers optometric services, and identify a qualifying parameter for each patient served. I agree to provide a copy of the log to the Board office quarterly, via email.

  • Price: $600.00
  • Price: $0.00
  • $0.00
  • Date Format: MM slash DD slash YYYY
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  • NOTE: To avoid the 3.5% credit card processing fee, payment may be made by mail, with checks payable to NV State Board of Optometry, noting the purpose of the payment. The Board prefers that all applications, documents or forms be submitted electronically. No submissions will be processed or deemed submitted until payment is received.

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