Glaucoma Application - Nevada State Board of Optometry

FOR CERTIFICATION, BY CO-MANAGEMENT OR BY ENDORSEMENT, TO TREAT PERSONS WITH GLAUCOMA

You may qualify to treat glaucoma in two distinct ways:
1) by endorsement from another jurisdiction pursuant to NRS 636.2897
2) by co-management with an ophthalmologist pursuant to NRS 636.2893

Name*

License Number*

Email address to receive my glaucoma certificate*

Are you applying by endorsement?*

Yes
No

1. Do you hold a Nevada-issued Optometric Pharmaceutical Agent Certificate (OPAC), formerly known as Therapeutic Pharmaceutical Agents certificate (TPA)?*

Yes
No

2. Do you attest that you hold a current, unrestricted ability in another jurisdiction to treat persons diagnosed with glaucoma, and have not been reported to the National Practitioners Data Bank within the immediate last 5 years?*

Yes
No

3. Do you attest that you have engaged in not fewer than 50 glaucoma patient encounters, or have completed requirements to obtain the ability to treat glaucoma patients in another jurisdiction which were substantially similar to the requirements for a Nevada certificate?*

Yes
No

If you did not answer Yes to Questions 1-3, please upload an explanatory narrative and any relevant documents here:

Upload documents to be submitted*

Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 20 MB, Max. files: 10.

Maximum File Size limit 20 MB

Upload your glaucoma co-management documentation here:

Upload documents to be submitted*

Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 20 MB, Max. files: 10.

Maximum File Size limit 20 MB

Application Fee

Price:

Total

$0.00

Untitled*

Pursuant to NRS 636.2891(2), I attest that regardless of whether I have been issued a certificate to treat persons diagnosed with glaucoma pursuant to NRS 636.2895 or certification by endorsement pursuant to NRS 636.2897, I shall refer a patient diagnosed with glaucoma to an ophthalmologist for treatment if any one of the following is applicable:

(a) The patient is under 16 years of age.
(b) The patient has been diagnosed with any type of glaucoma other than open angle glaucoma.
(c) The patient has been diagnosed with acute closed angle glaucoma. The provisions of this paragraph do not prohibit the
optometrist from administering any appropriate, nonsurgical emergency treatment to the patient.

Untitled*

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.

Name*

First

Date

Billing Address*

Street Address City State ZIP Code

Credit Card*

American Express

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MasterCard

Visa

JCB

Maestro

Card Number Expiration Date Security Code Cardholder Name

NOTE: Payments may be made by mail, enclosing a check payable to NV State Board of Optometry, noting the purpose of the payment and the name of the license. However, the Board prefers that all applications, documents or forms be submitted electronically. No submissions will be processed or deemed submitted until payment has been received.

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