Health Maintenance Organization Employment Registration

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NEVADA STATE BOARD OF OPTOMETRY

Post Office Box 1824
Carson City, Nevada 89702
Telephone: (775) 883-8367
Facsimile: (775)305-0105
E-Mail: admin@nvoptometry.org

NRS 636.347 Permit required for professional association with health maintenance organization; regulations.

1. No licensee may be employed by or contract with a health maintenance organization to provide services therefor unless the licensee has obtained a permit to do so from the Board.
2. Written application for a permit must be made on a form prescribed by the Board. The Board shall adopt reasonable regulations prescribing the procedure for obtaining a permit pursuant to this section.
3. For the purposes of this section, “health maintenance organization” has the meaning ascribed to it in NRS 695C.030.

Health Maintenance Organization Employment Registration

Name*

License #*

Email Address*

Name of HMO*

HMO Practice Location Address*

Street Address City State ZIP Code

Phone*

Are you an employee of this HMO?

Yes
No

Are you an independent contractor of this HMO?

Yes
No

Is this now your primary location?*

Yes
No

Do you have a Nevada Optometry License Certificate to hang at this location?*

No, I need to request a Duplicate Certificate.
Yes, I am no longer practicing at

This location address*

Address City State ZIP

I am no longer practicing at this location address*

Address City State ZIP

Where do you want your license certificate mailed to?*

Address City State ZIP Code

Addr./Loc. Change Fee*

Price:

Location Change Fee

Price:

Duplicate License Certificate

Price:

Total

$0.00

Do you or your business entity own any percentage of this optometric practice location?*

No. Continue to next section.
Yes. By checking this box, I affirm per NAC 636.215(5) that "Not later than 90 calendar days after any percentage of the ownership of an optometry practice for which a fictitious or assumed name is registered changes, the licensee to whom the fictitious or assumed name is registered must submit a new application for the registration of the assumed or fictitious name."

I attest that in the event the Board issues a subpoena for medical records or other materials regarding the optometric services I render by and through this HMO that I have access to and can facilitate the production of all such records or other materials.*

I attest that in the event the Board issues a subpoena for medical records or other materials regarding the optometric services I render by and through this HMO that I have access to and can facilitate the production of all such records or other materials. *

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 a person to complete or submit this information on my behalf, I, the optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of the submission.*

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 a person to complete or submit this information on my behalf, I, the optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of the submission. *

Name*

First

Date*

Billing Address*

Street Address City State ZIP Code

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. Please make all checks to the Nevada State Board of Optometry and mail them to P.O. Box 1824, Carson City, NV 89702.

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