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.

Mobile Optometry Clinic Quarterly Location Log PDF

“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 NRS 636.2899 and NAC 636. 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 NRS 636.2899 and NAC 636.

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 medically underserved group and others.

, 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 medically underserved group and others identified in NRS and NAC Chapters 636.

“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.

choose one or more:

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.

Name of clinic (as applicable)

Mailing address*

Street Address City State ZIP Code

Email*

Home Phone

Cell Phone*

Choose one :

Renewal of Mobile Clinic certification ($600).
New clinic: Application ($75) and initial certification ($562.50) prorated quarterly.

Application Fee

Price:

Application Fee

Price:

Penalty Fee

Price:

Quarterly Proration Schedule ($75 non-refundable application fee plus $93.75 for each calendar quarter for a 2-year license).
Quarter	Even Years	Odd Years
March 1 – May 31	$825.00	$450.00
June 1 – August 31	$731.25	$356.25
September 1 – November 30	$637.50	$262.50
December 1 – February 28 or 29	$543.75	$168.75

Total

$0.00

By submitting this information and checking this box, I affirm that each document is complete and correct and that all information contained in this submission is true under the pains and penalties of perjury and the requirements of NRS Chapter 636 and NAC Chapter 636 and Nevada law generally. I also acknowledge that if I have directed or authorized another to complete or submit this information on my behalf, I, the optometrist licensed by the Nevada Board of Optometry or the person authorized by a non-profit or governmental agency, am fully responsible for the content of this submission.

Credit card information:

Name*

Date*

Billing Address*

Street Address City State ZIP Code

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

NOTE: 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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