HomeAcademicsHealth SciencesElon PA - CharlotteClinical Site Letter of Intent Clinical Site Letter of Intent Clinical Site Letter of Intent for the Elon University PA Program in Charlotte Thank you for your participation as a preceptor for the Elon University Physician Assistant Program in Charlotte. We are excited to partner together. Preceptor InformationName(Required) First Last Title(Required) MD DO PA NP Other For MD/DO, do you currently hold board certification?(Required) Yes No If no, have you previously held board certification(Required) Yes No What is the certifying body?(Required)Optional. Please upload a copy of your certification letter/card/certificate hereMax. file size: 49 MB.For PAs, are you currently NCCPA certified?(Required) Yes No If no, have you previously been NCCPA certified?(Required) Yes No What is you NCCPA Number?(Required)For NPs, do you currently have or previously held board certification?(Required) Yes No Please upload a copy of your certification letter/card/certificate Drop files here or Select files Max. file size: 49 MB. If other please write here:(Required)Email(Required) Phone Number(Required)Please upload CV(Required)Max. file size: 49 MB.Are you board certified?(Required) Yes No Clinical Site InformationContact Person(Required) First Last Clinic/Practice Name(Required)Clinic/Practice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Contact Person Phone Number(Required)Contact Person Email(Required) Is the practice in a rural or underserved area?(Required) Yes No Affiliation Agreement InformationSignatory Name (who may legally sign the Affiliation Agreement for your facility)(Required)Signatory Email(Required)Organization/Facility Name(Required)Rotation/Setting InformationRotation Discipline(Required)Internal Medicine-6 weeksFamily Medicine- 6 weeksPediatrics- 6 weeksWomen's Health (OB/GYN)- 3 weeksBehavioral Medicine- 3 weeksSurgery- 6 weeksEmergency Medicine- 6 weeksOther (specify below)Number of PA students you are willing to precept per year:(Required)Please enter a number less than or equal to 99.Please select all settings that apply for rotation(Required) Inpatient Outpatient Emergency Room Operating Room Select AllDoes your practice use telehealth/telemedicine?(Required) Yes No If yes, what percentage of this rotation's patient care would be via telehealth/telemedicine?Preferred Months for Precepting January February March April May June July August September October November December Electronic SignatureThis signed form signifies the intent to participate in the clinical education of Elon University Physician Assistant Program students. Exact rotation dates to be determined. Signature(Required)By signing this document I authorize all information to be used for the Elon University Physician Assistant program and consent this as my electronic signature.Date Signed(Required) MM slash DD slash YYYY The Elon University Physician Assistant (PA) Program in Charlotte has applied for Accreditation-Provisional from the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The Elon University Physician Assistant (PA) Program in Charlotte anticipates matriculating its first class in January 2027, pending achieving Accreditation-Provisional status at the September 2026 ARC-PA meeting. Accreditation-Provisional is an accreditation status granted when the plans and resource allocation, if fully implemented as planned, of a proposed program that has not yet enrolled students appear to demonstrate the program’s ability to meet the ARC-PA Standards or when a program holding accreditation-provisional status appears to demonstrate continued progress in complying with the Standards as it prepares for the graduation of the first class (cohort) of students. Please note that the program will not commence in the event that the provisional accreditation is not received. UntitledCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
