This chapter governs the practice of physician assistants and collaboration between physician assistants and one or more patient care team physicians. This chapter does not prohibit: A student from performing any of the procedures described in these regulations as part of an accredited school's clinical curriculum; An individual from practicing a health occupation that the individual is authorized to practice under Health Occupations Article, Annotated Code of Maryland; or A physician assistant employed by the federal government from performing duties incident to that employment. In this chapter, the following terms have the meanings indicated. Terms Defined. “Accredited” means accredited by the Accreditation Review Commission on Education for the Physician Assistant or its successor. “Advanced duties” means medical acts that require additional education, training, or experience that is beyond the physician assistant education program required for licensure. “Ambulatory surgical facility” means a facility: Accredited by: The American Association for Accreditation of Ambulatory Surgical Facilities; The Accreditation Association for Ambulatory Health Care; or The Joint Commission on the Accreditation of Health Care Organizations; or Certified to participate in the Medicare Program, as enacted by Title XVIII of the Social Security Act. “Applicant” means an individual who applies to the State Board of Physicians for licensure as a physician assistant. “Board” means the State Board of Physicians. “Category I hours” means hours of continuing medical education given in formally organized programs pertinent to the practice of physician assistant duties, accredited by the American Academy of Physician Assistants, the American Academy of Family Physicians, the Accreditation Council on Continuing Medical Education, the Medical and Chirurgical Faculty of Maryland, or equivalent certifying bodies. “Collaborating physician” means one or more patient care team physicians who collaborate with a physician assistant under a collaboration agreement. Collaboration. “Collaboration” means the communication and decision-making process among health care providers who are members of a patient care team related to the treatment of a patient which includes the degree of cooperation necessary to provide treatment and care to the patient. “Collaboration” includes: Communication of data and information about the treatment and care of a patient, including the exchange of clinical observations and assessments; and The development of an appropriate plan of care including decisions regarding the health care provided, accessing and assessing appropriate additional resources, expertise, referrals, testing, or studies. “Collaboration” does not require constant, physical presence of a collaborating physician on-site in the practice setting provided that the collaborating physician is accessible by electronic means. “Collaboration agreement” means a document that outlines the relationship between a physician assistant and an individual physician or a group of physicians which is maintained at the practice level and is developed between a physician assistant and collaborating physician or physicians. “Committee” means the Physician Assistant Advisory Committee. “Controlled dangerous substances” means any drug listed as such in Criminal Law Article, Annotated Code of Maryland. “Core duties” means medical acts that are included in the standard curricula of accredited physician assistant education programs. “Correctional facility” means a State or local correctional facility. “Detention center” means a State or local detention center. “Drug sample” means a unit of a prescription drug that is intended to promote the sale of the drug and is not intended for sale. “English-speaking professional school” means a school: That offers a degree after graduation from high school; That is in the United States, its territories and possessions, or the British Commonwealth; and Where all academic and clinical courses are taught in English. “Exempt facility” means: A hospital; An ambulatory surgical facility; A federally qualified health center as defined in Health-General Article, §24-1301(b), Annotated Code of Maryland; or Any other practice setting listed on a hospital delineation of privileges document. “Hospital” means: A hospital as defined under Health-General Article, §19-301(g), Annotated Code of Maryland; A comprehensive care facility that: Meets the requirements of a hospital-based skilled nursing facility under 42 U.S.C. §1395i-3; and Offers acute care in the same building; and An emergency room that is physically connected to a hospital or a freestanding medical facility that is licensed under Health-General Article, Title 19, Subtitle 3A, Annotated Code of Maryland. “Joint Commission” means the organization formerly known as the Joint Commission on Accreditation of Health Care Organizations. “NCCPA” means the National Commission on Certification of Physician Assistants, Inc. “On-site” means the physical presence of the collaborating physician on the premises of the facility where the physician assistant performs delegated medical acts. “Patient care team” means a multidisciplinary team of health care providers actively functioning as a unit with the leadership of one or more patient care team physicians for the purpose of providing and delivering health care to a patient or group of patients. “Patient care team physician” means a licensed physician who regularly practices in the State and who provides leadership in the care of patients as part of a patient care team. “Physician” means an individual who is licensed by the Board to practice medicine. “Physician assistant” means an individual who is licensed by the Board to practice as a physician assistant. “Prescriptive authority” means the authority of a physician assistant to: Prescribe and administer: Controlled dangerous substances; Prescription drugs; and Medical devices; Give verbal, written, or electronic orders for medications; and Dispense starter dosages or drug samples. “Public health facility” means a site where clinical public health services are rendered under the auspices of the Department, a local health department in a county, or the Baltimore City Health Department. “Starter dosage” means an amount of a drug sufficient to begin therapy: Of short duration of 72 hours or less; or Before obtaining a larger quantity of the drug to complete therapy. “Training” means the education or on-the-job training a physician assistant: Receives after initial licensure as a physician assistant; and Requires to perform advanced duties. Composition. The Physician Assistant Advisory Committee shall be composed as required under Health Occupations Article, §15-202, Annotated Code of Maryland. Tenure. The term of a member is 3 years. The initial terms of the members are staggered. At the end of a term, a member continues to serve until a successor is appointed. An individual may be reappointed for a second term but an individual may not serve more than two consecutive terms. Vacancy. If a vacancy occurs for a physician or physician assistant, the Board shall appoint a new member in the same category. Officers. A Committee chairperson shall be elected every 2 years by a majority vote of the membership of the Committee. Removal. Upon the recommendation of the chairman, the Board, by a majority, may vote to remove any member of the Committee for: Neglect of duty, including but not limited to: Failure to attend two successive committee meetings without adequate reason; Failure to attend Board mandated training; or Failure to complete necessary ethics filing requirements; Malfeasance; Misfeasance; Misconduct; or Incompetency. The Committee shall: Upon request, review selected applications for licensure, renewal, or reinstatement of physician assistants and make recommendations to the Board as to what action to take on the applications; Review each advanced duty which requires prior approval by the Board and, as needed, interview each physician assistant and one or more patient care team physicians to make recommendations to the Board; Make recommendations to the Board regarding regulations governing physician assistants; and Advise the Board on matters related to the practice of physician assistants. The Committee may delegate a physician member and a physician assistant member of the Committee to conduct the interview of each physician assistant and patient care team physician, as permitted under §F(2) of this regulation. Except as otherwise provided under Health Occupations Article, Title 15, Annotated Code of Maryland, an individual shall be licensed by the Board and notify the Board of an executed collaboration agreement before the individual may practice as a physician assistant or collaborate with a patient care team physician. A physician assistant's scope of practice will be limited to medical acts that are: Appropriate to the education, training, and experience of the physician assistant; Customary to the practice of a patient care team physician; and Performed in a manner consistent with the collaboration agreement. A physician assistant may delegate technical medical acts authorized under Health Occupations Article, §14-306, Annotated Code of Maryland and COMAR 10.32.12 provided the physician assistant: Has notified the Board, in a manner approved by the Board of an executed collaboration agreement; and Has completed at least 7,000 hours of clinical practice experience. Prohibitions. Regardless of the setting or other factors, a patient care team physician may not delegate, and a physician assistant may not perform general anesthesia or neuraxial anesthesia, including spinal, epidural, and image-guided interventional spine procedures. Except in hospitals, detention centers, correctional facilities, and public health facilities, a patient care team physician may not collaborate with more than eight physician assistants during the same shift. Application. Applicants shall: Complete an application on a form approved by the Board; Pay an application fee as defined in Regulation .16 of this chapter; Be at least 18 years old; Be of good moral character; and Demonstrate oral and written competency in English by one or more of the following: Graduation from a recognized English-speaking high school or undergraduate school after at least 3 years of enrollment; Graduation from a recognized English-speaking professional school; or Receiving a grade of: At least 26 on the Speaking Section of the Internet-based Test of English as a Foreign Language; and At least 79 on the Internet-based Test of English as a Foreign Language. Education. An applicant who has successfully completed an educational program for physician assistants shall: Have graduated from a physician assistant program accredited by The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), its predecessor, or its successor; and Have passed the physician assistant national certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA) or its successor. In addition to the requirement specified in §B(1) of this regulation, an applicant who has successfully completed an educational program for physician assistants after October 1st, 2003, shall have one of the following: A bachelor’s degree; or At least 120 credit hours of education at the college or university level. Primary Source Verification. The Board may accept the Federation Credential Verification Service for primary source verification of a physician assistant's education and examination. Before a physician assistant may perform medical acts, the physician assistant shall: Execute a collaboration agreement between the physician assistant and one or more patient care team physicians; Notify the Board in a manner approved by the Board of the executed collaboration agreement; and Maintain a copy of the executed collaboration agreement on file at the physician assistant’s primary practice location. Collaboration Agreement Requirements. A collaboration agreement may only consist of one physician assistant and one or more patient care team physicians practicing at the same facility. A physician assistant shall have a separate collaboration agreement for each of the physician assistant’s employers. The physician assistant has the affirmative obligation to retain the collaboration agreement and all of the documentation pertaining to the collaboration agreement for 5 years after termination of the collaboration agreement for Board inspection. Contents. The collaboration agreement shall include, at minimum: Each patient care team physician’s name and Maryland license number; A description of each patient care team physician’s qualifications to collaborate with a physician assistant; The practice specialty of each listed patient care team physician; The physician assistant’s name and Maryland license number; The primary location and settings where the physician assistant will practice; The employer of the physician assistant; A description of the settings where the physician assistant will practice; Any delegation of prescriptive authority and, if applicable, dispensing according to Regulation .08 of this chapter; and Any other information deemed necessary by the Board to carry out the provisions of Health Occupations Article, Title 15, Annotated Code of Maryland. The collaboration agreement may include a description of any provisions established by the listed patient care team physicians that: Detail the practice of the physician assistant; Limit the physician assistant's scope of practice; or Specify office procedures. The physician assistant shall attest that: All medical acts performed by the physician assistant shall be: Appropriate to the education, training, and experience of the physician assistant; Customary to the practice of a patient care team physician listed on the collaboration agreement; and Performed in a manner consistent with the collaboration agreement; and Any performance of an advanced duty in collaboration with a patient care team physician shall be in accordance with Health Occupations Article, §15-302.1, Annotated Code of Maryland. Each collaborating physician shall document their official acknowledgment of their understanding and status as a listed patient care team physician on the collaboration agreement with the physician assistant. A physician assistant that has sufficient education, training, and experience in the performance of an advanced duty, may perform that advanced duty under a collaboration agreement without Board approval if: The physician assistant is practicing at an exempt facility in accordance with Health Occupations Article, §15–302.1, Annotated Code of Maryland and meets the conditions in §A(4) of this regulation; The physician assistant has previously received Board approval to perform the advanced duty; or The physician assistant has at least 7,000 hours of clinical practice experience as attested to by the physician assistant. For a physician assistant practicing at an exempt facility the following shall be met: The patient care team physician listed on the collaboration agreement has been credentialed by the exempt facility as a condition of employment; The physician assistant listed on the collaboration agreement has been credentialed by the exempt facility as a condition of employment; and The advanced duty to be delegated by the patient care team physician to the physician assistant is reviewed and approved in a process approved by the exempt facility before the physician assistant performs the advanced duty. Except as provided under §A of this regulation, a physician assistant shall receive Board approval to perform an advanced duty prior to performing the advanced duty. A physician assistant performing X-Ray duties in accordance with Health Occupations Article, §14–306(e), Annotated Code of Maryland, shall: Notify the Board of an executed collaboration agreement in a manner approved by the Board; Maintain a copy of the collaboration agreement on file at the practice location; Obtain Board approval for the X-Ray duty as an advanced duty if practicing at a location other than an exempt facility; Perform the X-Ray duty in the medical office of a patient care team physician; and Be limited to nonfluoroscopic X-Ray procedures of the extremities, anterior-posterior and lateral, not including the head. In addition to the requirements of §C of this regulation, a physician assistant performing the advanced duty of nonfluoroscopic X-ray procedures using a mini C-arm or similar low-level radiation machine shall be required to present the Board with evidence of completion of a course that includes: Didactic instruction of at least eight hours on the following subject matters: Principles of radiography; Image acquisition; Principles of exposure; Image evaluation; Radiation safety; Equipment overview; and Documentation; and Clinical instruction, which shall: Include anterior-posterior and lateral radiographic studies of extremities, not including the head, on at least 20 separate patients; and Be under the direct supervision of the delegating physician or radiologist. Approvals of Advanced Duties. Documentation demonstrating a physician assistant’s authority to perform an advanced duty under this section shall be maintained at the facility where the physician assistant is performing the advanced duty. The Board may audit and review collaboration agreements kept by the physician assistant at the primary place of business of the licensee at any time. If an advanced duty requires Board approval, the Committee: Shall review the collaboration agreement; May conduct a personal interview of the physician assistant and patient care team physicians; or May recommend to the Board that the collaboration agreement be modified to ensure conformance with the requirements of Health Occupations Article, §§15–302 and 15–302.1, Annotated Code of Maryland. Modification or Disapproval of Advanced Duties. The Board may modify or disapprove the performance of advanced duties under a collaboration agreement if the physician assistant does not meet the applicable education, training, and experience requirements to perform the specified advanced duties. If the Board disapproves or modifies a request to perform an advanced duties, the Board shall: Notify the delegating patient care team physician listed in the collaboration agreement and the physician assistant in writing of the particular elements of the advanced duty approval request that were the cause for the modification or denial; Set forth the specific reasons for the modification or denial; and Give the applicant an opportunity to submit an amendment to the advanced duty or request a hearing before the Board. To request a hearing regarding modification or disapproval of advanced duties, the applicant shall make a written request for a hearing within 30 days of the receipt of the notice of modification or disapproval. Physician Assistant Deemed Ineligible to Perform an Advanced Duty. A physician assistant who applies to perform an advanced duty may be deemed ineligible to perform an advanced duty if the physician assistant or patient care team physician: Fails to complete the application; Fails to provide additional information requested by the Board in connection with the application; or Submits false or misleading information to the Board in connection with the application. If a physician assistant is deemed ineligible to perform the advanced duty, the Board shall: Give written notice to the applicant; and Set forth the specific reasons for the ineligibility. A physician assistant who is deemed ineligible to perform the advanced duty shall not be authorized to perform the advanced duty except for training purposes under the direct supervision of a patient care team physician listed on the collaboration agreement. Individual members of the Board are not civilly liable for actions regarding the approval, modification, or disapproval of an advanced duty under the collaboration agreement described in this regulation. In order for a patient care team physician to delegate prescriptive authority, the [primary supervising] patient care team physician shall ensure that the collaboration agreement includes: A statement describing whether the physician intends to delegate any of the following: Prescribing of: Controlled dangerous substances; Prescription drugs; or Medical devices; Giving verbal, written, or electronic orders for medications; Dispensing starter dosages or drug samples; An attestation that all prescribing activities of the physician assistant will comply with applicable federal and State regulations; An attestation that all medical charts and records will contain a notation of any prescriptions written by a physician assistant; An attestation that all prescriptions dispensed include the physician assistant's name and the patient care team physician’s name, business address, and business telephone number legibly written or printed; An attestation that the physician assistant has: Passed the physician assistant national certification exam administered by the National Commission on the Certification of Physician Assistants, Inc. within the previous 2 years; or Completed 8 Category I hours of pharmacology education within the previous 2 years; and An attestation that the physician assistant has at least one of the following: A bachelor's degree or its equivalent; or 2 years of work experience as a physician assistant. Dispensing of Drug Samples and Starter Dosages of Drugs by Physician Assistant. A drug sample or starter dosage shall meet the following criteria before a physician assistant may dispense the drug sample or starter dosage: Package is labeled as required by Health Occupations Article, §12-505, Annotated Code of Maryland; and No charge is made for the drug sample or starter dosage. A physician assistant shall enter an appropriate note in the patient’s medical record. A physician assistant may not delegate dispensing of drug samples or starter dosages. Renewal. The Board may not renew a license until the Comptroller of Maryland has verified that the individual has paid all undisputed taxes and unemployment insurance contributions, or arranged for repayment, as required by COMAR 10.31.02. An individual who has been licensed by the Board as a physician assistant may renew the license every 2 years on the date specified by the Board by: Completing an application on a form approved by the Board; Paying the required renewal fee as defined in Regulation .16 of this chapter; Attesting to completion of continuing education activities as specified in §D of this regulation; and Meeting any additional requirements set by the Board for renewal of a license. Reinstatement. The Board shall reinstate the license of a physician assistant if the physician assistant: Completes an application on a form approved by the Board; Pays the required reinstatement fee as defined in Regulation .16 of this chapter; Submits evidence of completion of continuing education activities as specified in §D of this regulation; and Meets any additional requirements set by the Board for reinstatement of a license. Change in Name or Address. A physician assistant shall notify the Board in writing of a change in the physician assistant's name or address within 60 days after the change. If a physician assistant fails to notify the Board within the time required under §C(1) of this regulation, the physician assistant is subject to an administrative penalty of $100. Continuing Education. Except as specified in §D(2) of this regulation, in order to renew or reinstate a license under §A or B of this regulation, a physician assistant shall complete at least 50 hours of continuing education consisting of: At least 8 hours of Category 1 education on pharmacology topics earned during the 2-year period preceding: For license renewal, the expiration of the physician assistant license; or For license reinstatement, the date of the submission of the application for reinstatement; and In addition to the continuing education hours specified in §D(1)(a) of this regulation, at least 42 hours of Category I continuing education earned during the 2-year period preceding: For license renewal, the expiration of the physician assistant license; or For license reinstatement, the date of the submission of the application for reinstatement. A physician assistant who is renewing a license as a physician assistant for the first time since either initial licensure or reinstatement of a license: Shall earn at least 8 hours of Category 1 education on pharmacology topics prior to the expiration of the physician assistant license; and Is not required to complete any other hours of Category I continuing education prior to the expiration of the physician assistant license. Documentation of Continuing Education. A physician assistant shall obtain documentation of attendance at Category I continuing education and retain the documentation for 6 years. The documentation shall contain, at a minimum, the following information: Program title; Sponsor’s name; Physician assistant’s name; Inclusive date or dates and location of the program; Category I designation and the number of continuing education hours earned; and Documented verification that the physician assistant attended the program by stamp, signature, printout, or other official proof. Proof of maintenance of certification by the National Commission on Certification of Physician Assistants may be used to document compliance with the continuing education requirement. The Board may request a physician assistant to submit evidence of having met the continuing education requirements specified in this regulation. If a physician assistant cannot demonstrate completion of the required continuing education credit hours, the Board may impose a civil penalty of up to $100 per missing continuing education credit hour. A physician assistant shall: Wear an identification tag or badge which identifies that individual as a physician assistant; Identify himself or herself to all patients as a physician assistant; and Maintain a copy of the physician assistant’s license and collaboration agreement at the practice setting. An individual may not identify himself or herself as a physician assistant unless licensed by the Board. A physician assistant shall: Notify the Board in a manner approved by the Board of an executed collaboration agreement developed by the listed patient care team physician or physicians and the physician assistant; Collaborate with a patient care team physician for medical acts that: Are customary to the practice of a listed patient care team physician; and Are suitable to be performed by the physician assistant, taking into account the physician assistant’s: Education; Training; and Experience; Obtain approval for any advanced duties; and; Update the practitioner profile to report the termination of a collaboration agreement for any reason to the Board within 5 days, providing the following information: Name and license number of the patient care team physician and physician assistant; and Reason for termination, including a description of conduct or incident that resulted in the termination. Sudden Departure of the Patient Care Team Physician. In the event of the sudden departure, incapacity, or death of a patient care team physician, or in a change in licensure status that results in a patient care team physician being unable to practice medicine in the State, the collaboration agreement will remain active and valid under the supervision of any remaining listed patient care team physicians. If no remaining patient care team physicians are listed on the collaboration agreement, the physician assistant may not practice until the physician assistant has executed a new collaboration agreement and provided notification to the Board. The Board may deny a license, reprimand a physician assistant, place a physician assistant on probation, or suspend or revoke a license if the physician assistant: Fraudulently or deceptively obtains or attempts to obtain a license for the applicant or the licensee or for another; Fraudulently or deceptively uses a license; Is guilty of: Immoral conduct in the practice of medicine; or Unprofessional conduct in the practice of medicine; Is professionally, physically, or mentally incompetent; Solicits or advertises in violation of Health Occupations Article, §14-503, Annotated Code of Maryland; Abandons a patient; Is habitually intoxicated; Is addicted to, or habitually abuses, any narcotic or controlled dangerous substance as defined in Criminal Law Article, §5-101, Annotated Code of Maryland; Provides professional services: While under the influence of alcohol; or While using any narcotic or controlled dangerous substance, as defined in Criminal Law Article, §5-101, Annotated Code of Maryland, or other drug that is in excess of therapeutic amounts or without valid medical indication; Promotes the sale of drugs, devices, appliances, or goods to a patient so as to exploit the patient for financial gain; Willfully makes or files a false report or record in the practice of medicine; Willfully fails to file or record any medical report as required under law, willfully impedes or obstructs the filing or recording of the report, or induces another to fail to file or record the report; On proper request, and in accordance with the provisions of Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland, fails to provide details of a patient's medical record to the patient, another physician, or hospital; Solicits professional patronage through an agent or other person or profits from the acts of a person who is represented as an agent of the physician assistant; Pays or agrees to pay any sum to any person for bringing or referring a patient or accepts or agrees to accept any sum from any person for bringing or referring a patient; Agrees with a clinical or bioanalytical laboratory to make payments to the laboratory for a test or test series for a patient, unless the licensed physician assistant discloses on the bill to the patient or third-party payor: The name of the laboratory; The amount paid to the laboratory for the test or test series; and The amount of procurement or processing charge of the licensed physician, if any, for each specimen taken; Makes a willful misrepresentation in treatment; Practices medicine with an unauthorized person or aids an unauthorized person in the practice of medicine; Grossly over-utilizes health care services; Offers, undertakes, or agrees to cure or treat disease by a secret method, treatment, or medicine; Is disciplined by a licensing or disciplinary authority or convicted or disciplined by a court of any state or country or disciplined by any branch of the United States uniformed services or the Veterans' Administration for an act that would be grounds for disciplinary action under Health Occupations Article, §15-314, Annotated Code of Maryland; Fails to meet appropriate standards as determined by appropriate peer review for the delivery of quality medical and surgical care performed in an outpatient surgical facility, office, hospital, or any other location in this State; Willfully submits false statements to collect fees for which services are not provided; Was subject to investigation or disciplinary action by a licensing or disciplinary authority or by a court of any state or country for an act that would be grounds for disciplinary action under this regulation and the licensee: Surrendered the license issued by the state or country to the state or country; or Allowed the license issued by the state or country to expire or lapse; Knowingly fails to report suspected child abuse in violation of Family Law Article, §5-704, Annotated Code of Maryland; Fails to educate a patient being treated for breast cancer of alternative methods of treatment as required by Health-General Article, §20-113, Annotated Code of Maryland; Sells, prescribes, gives away, or administers drugs for illegal or illegitimate medical purposes; Fails to comply with the provisions of Health Occupations Article, §12-102, Annotated Code of Maryland; Refuses, withholds from, denies, or discriminates against an individual with regard to the provision of professional services for which the licensee is licensed and qualified to render because the individual is HIV positive; Except as to an association that has remained in continuous existence since July 1, 1963: Associates with a pharmacist as a partner or co-owner of a pharmacy for the purpose of operating a pharmacy; Employs a pharmacist for the purpose of operating a pharmacy; or Contracts with a pharmacist for the purpose of operating a pharmacy; Except in an emergency life-threatening situation where it is not feasible or practicable, fails to comply with the Centers for Disease Control and Prevention's guidelines on universal precautions; Fails to display the notice required under Health Occupations Article, §14-415, Annotated Code of Maryland; Fails to cooperate with a lawful investigation conducted by the Board; Is convicted of insurance fraud as defined in Insurance Article, §27-801, Annotated Code of Maryland; Is in breach of a service obligation resulting from the applicant's or licensee's receipt of State or federal funding for the licensee's medical education; Willfully makes a false representation when seeking or making application for licensure or any other application related to the practice of medicine; By corrupt means, threats, or force, intimidates or influences, or attempts to intimidate or influence, for the purpose of causing any person to withhold or change testimony in hearings or proceedings before the Board or those otherwise delegated to the Office of Administrative Hearings; By corrupt means, threats, or force, hinders, prevents, or otherwise delays any person from making information available to the Board in furtherance of any investigation of the Board; Intentionally misrepresents credentials for the purpose of testifying or rendering an expert opinion in hearings or proceedings before the Board, a disciplinary panel, or those otherwise delegated by the Office of Administrative Hearings; Fails to keep adequate medical records; Performs medical acts in a manner that is not consistent with the collaboration agreement; Performs medical acts which are outside the education, training, and experience of the physician assistant; Performs medical acts that are not customary to the practice of the patient care team physicians listed on the collaboration agreement; Practices as a physician assistant without first providing notice to the Board as required under Health Occupations Article, §15–302(A), Annotated Code of Maryland; Fails to complete a criminal history records check under Health Occupations Article, §14–308.1, Annotated Code of Maryland; Fails to comply with the requirements of the Prescription Drug Monitoring Program set forth in Health-General Article, Title 21, Subtitle 2A, Annotated Code of Maryland; or Fails to comply with any State or federal law or regulation pertaining to the practice of a physician assistant. Unprofessional conduct in the practice of medicine, Health Occupations Article, §14-404(a)(3), Annotated Code of Maryland, includes the failure of a physician to comply with the statute and regulations governing the physician's duty to supervise the physician assistant. Except as provided in §B of this regulation, a hospital, related institution, alternative health care system, and employer physician shall file with the Board a report that the hospital, related institution, alternative health system, or employer physician limited, reduced, otherwise changed, or terminated any licensee for any reason that might be grounds for disciplinary action under Regulation .13 of this chapter or Health Occupations Article, Titles 14 and 15, Annotated Code of Maryland. Exception. A hospital, related institution, alternative health system, or employer that has reason to know that a licensee has committed an action or has a condition that might be grounds for reprimand or probation of the licensee or suspension or revocation of the licensure because the licensee is alcohol impaired or drug impaired is not required to report the licensee to the Board if: The hospital, related institution, alternative health system, or employer knows that the licensee is: In an alcohol or drug treatment program that is accredited by the Joint Commission or is certified by the Maryland Department of Health; or Under the care of a health care practitioner who is competent and capable of dealing with alcoholism and drug abuse; The hospital, related institution, alternative health system, or employer is able to verify that the licensee remains in the treatment program until discharge; and The action or condition of the licensee or holder of a temporary license has not caused injury to any person while the licensee or holder of a temporary license is practicing. Notice by Licensee. If the licensee enters, or is considering entering, an alcohol or drug treatment program that is accredited by the Joint Commission or that is certified by the Maryland Department of Health, the licensee shall notify the hospital, related institution, alternative health system, employer, or patient care team physician of the licensee's or holder's decision to enter the treatment program. If the licensee fails to provide the notice required under §C(1) of this regulation, and the hospital, related institution, alternative health system, employer, or patient care team physicians learn that the licensee has entered a treatment program, the hospital, related institution, alternative health system, employer, or patient care team physician shall report to the Board that the licensee has entered a treatment program and has failed to provide the required notice. If the licensee is found to be noncompliant with the treatment program's policies and procedures while in the treatment program, the treatment program shall notify the hospital, related institution, alternative health system, employer, or patient care team physician of the licensee's noncompliance. Examination. The Board may direct a physician assistant who is an applicant or licensee to submit to an appropriate examination to determine the physician assistant’s physical, mental, or professional ability to perform delegated medical acts. A physician assistant is deemed to have consented to an examination and waived any claim to privilege as to the examination report. The unreasonable failure or refusal of an applicant or licensee to submit to an examination is: Prima facie evidence that the physician assistant cannot perform delegated medical acts; and Cause for denial of an application or suspension of a license. Entry. The executive director of the Board or other authorized representative or investigator may enter at any reasonable hour a place of business of a physician or physician assistant or into public premises: For the purpose of an audit to verify general compliance with the Maryland Physician Assistants Act; or To investigate an allegation with respect to a physician assistant. A person may not deny or interfere with an entry under §B(1) of this regulation. A person who violates any provision of §B(1) of this regulation is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $100. Audit. The Board’s representatives may require a physician, physician assistant, or facility where the physician assistant is employed or practicing to provide immediate access to any records relating to the physician assistant’s employment, credentialing, and practice and any medical records of patients seen by the physician assistant. The Board’s representative shall refer possible compliance issues to: The compliance section of the Board; or An outside agency that has jurisdiction over a facility. A physician, physician assistant, or facility who fails to comply with a Board audit in accordance with §C(1) of this regulation is subject to an administrative fine. A physician assistant who is licensed in this State or in any other state or who is an employee of the federal government is authorized to perform acts, tasks, or functions as a physician assistant during a disaster within a county in which a state of disaster has been declared by the Governor, or counties contiguous to a county in which a state of disaster has been declared, in accordance with Public Safety Article, §14-107, Annotated Code of Maryland. The physician assistant shall notify the Board in writing of their name, practice locations, and telephone numbers for the physician assistant within 30 days of the first performance of medical acts, tasks, or functions as a physician assistant during the disaster. A team of physicians and physician assistants or physician assistants practicing under this regulation may not be required to maintain on-site documentation describing collaboration agreements as otherwise required in Regulation .06 of this chapter. The following fees are applicable to physician assistants: Application fees: Initial application — $310 Endorsement application — $100 Reciprocity application — $100; and Reinstatement application — $400; Physician Assistant license fee per month until expiration of license .—. $10; Renewal fees: License renewal fee .—. $360; Maryland Health Care Commission (MHCC) fee ... As determined by MHCC under COMAR 10.25.03; and Preceptor fee — as determined in accordance with Health Occupations Article, §15–206(a)(2)(i), Annotated Code of Maryland; Written verification of licensure .—. $25; and Advanced Duty Application Fee — $100. General Application of Sanctioning Guidelines. Sections A and B of this regulation and Regulation .18A and B of this chapter do not apply to offenses for which a mandatory sanction is set by statute or regulation. Except as provided in §B of this regulation, for violations of the sections of the Physician Assistants Act listed in the sanctioning guidelines, the Board shall impose a sanction not less severe than the minimum listed in the sanctioning guidelines nor more severe than the maximum listed in the sanctioning guidelines for each offense. Ranking of Sanctions. For the purposes of this regulation, the severity of sanctions is ranked as follows, from the least severe to the most severe: Reprimand; Probation; Suspension; and Revocation. A fine listed in the sanctioning guidelines may be imposed in addition to but not as a substitute for a sanction. The addition of a fine does not change the ranking of the severity of the sanction. The Board may impose more than one sanction, provided that the most severe sanction neither exceeds the maximum nor is less than the minimum sanction permitted in the chart. Any sanction may be accompanied by conditions reasonably related to the offense or to the rehabilitation of the offender. The inclusion of conditions does not change the ranking of the sanction. If a licensee has violated more than one ground for discipline as set out in the sanctioning guidelines: The sanction with the highest severity ranking shall be used to determine which ground will be used in developing a sanction; and The Board may impose concurrent sanctions based on other grounds violated. Notwithstanding the sanctioning guidelines set forth in Regulation .18 of this chapter, in order to resolve a pending disciplinary action, the Board and the licensee may agree to a surrender of license or a consent order with terms, sanction, and fine agreed to by the Board, the administrative prosecutor, and the licensee. Depending on the facts and circumstances of each case, and to the extent that the facts and circumstances apply, the Board may consider the aggravating and mitigating factors set out in §B(4) and (5) of this regulation and may in its discretion determine, based on those factors, that an exception should be made and that the sanction in a particular case should fall outside the range of sanctions listed in the sanctioning guidelines. If the Board imposes a sanction that departs from the sanctioning guidelines as set forth in Regulation .18 of this chapter, the Board shall state its reasons for doing so in its final decision and order. Aggravating and Mitigating Factors. Depending on the facts and circumstances of each case, and to the extent that the facts and circumstances apply, the Board may consider the aggravating and mitigating factors set out in §B(4) and (5) of this regulation and may in its discretion determine, based on those factors, that an exception should be made and that the sanction in a particular case should fall outside the range of sanctions listed in the sanctioning guidelines. Nothing in this regulation requires the Board or an Administrative Law Judge to make findings of fact with respect to any of these factors. The existence of one or more of these factors does not impose on the Board or an Administrative Law Judge any requirement to articulate its reasoning for not exercising its discretion to impose a sanction outside of the range of sanctions set out in the sanctioning guidelines. Mitigating factors may include, but are not limited to, the following: The absence of a prior disciplinary record; The offender self-reported the incident; The offender voluntarily admitted the misconduct, made full disclosure to the Board, and was cooperative during the Board proceedings; The offender implemented remedial measures to correct or mitigate the harm arising from the misconduct; The offender made good faith efforts to make restitution or to rectify the consequences of the misconduct; The offender has been rehabilitated or exhibits rehabilitative potential; The misconduct was not premeditated; There was no potential harm to patients or the public or other adverse impact; or The incident was isolated and is not likely to recur. Aggravating factors may include, but are not limited to, the following: The offender has a previous criminal or administrative disciplinary history; The offense was committed deliberately or with gross negligence or recklessness; The offense had the potential for or actually did cause patient harm; The offense was part of a pattern of detrimental conduct; The offender committed a combination of factually discrete offenses adjudicated in a single action; The offender pursued his or her financial gain over the patient’s welfare; The patient was especially vulnerable; The offender attempted to hide the error or misconduct from patients or others; The offender concealed, falsified, or destroyed evidence or presented false testimony or evidence; The offender did not cooperate with the investigation; or Previous attempts to rehabilitate the offender were unsuccessful. A departure from the sanctioning guidelines set forth in Regulation .18 of this chapter is not a ground for any hearing or appeal of a Board action. Fines for Unauthorized Practice as a Physician Assistant. The Board may impose a fine not exceeding $5,000 as provided in §C(2) of this regulation for unauthorized practice as a physician assistant in violation of Health Occupations Article, §15-401, Annotated Code of Maryland. Factors in determining the amount of a fine include, but are not limited to the following: The extent to which the respondent derived any financial benefit from the improper conduct; The willfulness of the improper conduct; The extent of actual or potential public harm caused by the improper conduct; and The deterrent effect of the fine. The Board shall pay all monies collected pursuant to §C of this regulation into the Board of Physicians' fund. Employment of Unauthorized Individuals. A licensed physician, hospital, related institution, alternative health system, or employer may not employ an individual practicing as a physician assistant who does not have a license. A licensed physician may not supervise an individual practicing as a physician assistant who does not have a license. The Board may impose a fine of up to $1,000 for a violation of §D(1) or (2) of this regulation. Any funds collected under §D(3) of this regulation shall be deposited into the State's General Fund. Other Fines. The Board may impose a fine of $100 for a violation of Health Occupations Article, §15-309, Annotated Code of Maryland. The Board shall pay all monies collected pursuant to §E(1) of this regulation into the Board of Physicians' fund. Offenses Related to Continuing Medical Education Credits. First Offense of Failure to Document Credits. Except as provided in §F(2) or (3) of this regulation, if a licensee has submitted an application claiming the completion of continuing medical education credits and the licensee fails to document the completion of such continuing medical education credits when audited by the Board, the Board may impose a civil fine under Health Occupations Article, §15-307(f), Annotated Code of Maryland, of up to $100 per missing continuing medical education credit in lieu of a sanction under Health Occupations Article, §15-314, Annotated Code of Maryland. Section F(1)(a) of this regulation does not limit the Board's authority to require completion of the missing continuing medical education credits. Willful Falsification. If a licensee has willfully falsified an application with respect to continuing medical education credits, the licensee may be charged under one or more of the following, as appropriate: Health Occupations Article, §15-314(a)(3), Annotated Code of Maryland; Health Occupations Article, §15-314(a)(11), Annotated Code of Maryland; and Health Occupations Article, §15-314(a)(36), Annotated Code of Maryland. Upon a finding of a violation, the Board may impose any discipline authorized under Health Occupations Article, §15-314 or 15-316, Annotated Code of Maryland, and the sanctioning guidelines. Licensees Previously Disciplined Under §F(1) or (2) of this Regulation. If a licensee has been previously fined or otherwise disciplined under §F(1) or (2) of this regulation, the Board may, for a subsequent offense relating to continuing medical education credits, charge a licensee under one or more of the following, as appropriate: Health Occupations Article, §15-314(a)(3), Annotated Code of Maryland; Health Occupations Article, §15-314(a)(11), Annotated Code of Maryland; and Health Occupations Article, §15-314(a)(36), Annotated Code of Maryland. Upon a finding of a violation, the Board may impose any discipline authorized under Health Occupations Article, §15-314 or 15-316, Annotated Code of Maryland, and the sanctioning guidelines for a subsequent offense. The Board may not apply the sanction described in §F(1) of this regulation in determining a sanction for a licensee previously fined or disciplined for an offense related to continuing medical education credits. The Board shall pay all monies collected pursuant to §F of this regulation into the State's General Fund. Payment of Fines. An individual shall pay to the Board any fine imposed under this regulation within 15 calendar days of the date of the order, unless the order specifies otherwise. Filing an appeal under State Government Article, §10-222, Annotated Code of Maryland, does not stay payment of a fine imposed by the Board pursuant to this regulation. If an individual fails to pay, in whole or in part, a fine imposed by the Board pursuant to this regulation, the Board may not restore, reinstate, or renew a license until the fine has been paid in full. In its discretion, the Board may refer all cases of delinquent payment to the Central Collection Unit of the Department of Budget and Management to institute and maintain proceedings to ensure prompt payment. Health Occupations Article, §§1-213, 1-606, 14-205, 15-101—15-502, Annotated Code of Maryland Effective date: May 28, 1975 (2:12 Md. R. 870) Chapter revised effective October 26, 1981 (8:21 Md. R. 1708) Regulations .02 and .05F amended effective September 27, 1982 (9:19 Md. R. 1895) Regulations .05B-1 and .09A-1 adopted effective September 27, 1982 (9:19 Md. R. 1895) Regulations .01—.11 repealed effective March 18, 1991 (18:5 Md. R. 594) Regulations .01—.12 adopted effective March 18, 1991 (18:5 Md. R. 594) Regulations .02, .03, .06, .10, and .11 amended; Regulations .07—.09 and .12 repealed; and new Regulations .07—.09, .12, and .15 adopted as an emergency provision effective August 12, 1999 (26:18 Md. R. 1369); amended permanently effective January 24, 2000 (27:1 Md. R. 76) Regulations .02 and .05—.07 amended and new Regulation .06-1 adopted as an emergency provision effective November 8, 1996 (23:24 Md. R. 1676); emergency status expired October 1, 1997 Regulation .02B amended effective October 2, 1997 (24:17 Md. R. 1214); July 12, 1999 (26:14 Md. R. 1082) Regulation .04B amended effective July 12, 1999 (26:14 Md. R. 1082) Regulation .05B amended effective October 2, 1997 (24:17 Md. R. 1214) Regulation .06C amended effective November 22, 1993 (20:23 Md. R. 1804); October 2, 1997 (24:17 Md. R. 1214) Regulation .06D adopted effective October 2, 1997 (24:17 Md. R. 1214) Regulation .07A amended effective September 11, 1995 (22:18 Md. R. 1399) Regulation .07C adopted effective October 2, 1997 (24:17 Md. R. 1214) Regulation .11B amended effective April 25, 1994 (21:8 Md. R. 673) Regulation .13 adopted effective July 12, 1999 (26:14 Md. R. 1082) Regulation .14 adopted effective July 12, 1999 (26:14 Md. R. 1082) Chapter revised effective May 1, 2004 (31:7 Md. R. 584) Regulation .06D adopted as an emergency provision effective October 1, 2006 (33:24 Md. R. 1905); adopted permanently effective January 15, 2007 (34:1 Md. R. 32) Regulation .08C amended as an emergency provision effective October 1, 2006 (33:24 Md. R. 1905); amended permanently effective January 15, 2007 (34:1 Md. R. 32) Regulation .09C amended as an emergency provision effective October 1, 2006 (33:24 Md. R. 1905); amended permanently effective January 15, 2007 (34:1 Md. R. 32) Chapter revised as an emergency provision effective August 18, 2011 (38:19 Md. R. 1146); revised permanently effective October 3, 2011 (38:20 Md. R. 1202) Regulation .05C amended effective January 18, 2016 (43:1 Md. R. 14) Regulation .05F adopted effective November 7, 2016 (43:22 Md. R. 1221) Regulation .07 amended effective January 18, 2016 (43:1 Md. R. 14) Regulation .07A amended effective March 26, 2018 (45:6 Md. R. 320) Regulation .09 amended effective January 2, 2017 (43:26 Md. R. 1446) Regulation .09E adopted as an emergency provision effective January 4, 2022 (49:4 Md. R. 299); emergency status expired effective July 3, 2022 Regulation .17 adopted effective July 22, 2013 (40:14 Md. R. 1175) Regulation .18 adopted effective July 22, 2013 (40:14 Md. R. 1175) Chapter revised effective January 5, 2026 (52:26 Md. R. 1309) Annotation: COMAR 10.32.03 cited in Attorney General Opinion No. 86-008 (February 18, 1986)