CHAPTER 18. STATE BOARD OF MEDICINE
PRACTITIONERS OTHER THAN MEDICAL DOCTORS
Subchapter D. PHYSICIAN ASSISTANTS
§ 18.121. Purpose.
This subchapter implements section 13 of the act (63 P. S. § 422.13) pertaining to physician assistants and provides for the delegation of certain medical tasks to qualified physician assistants by supervising physicians when the delegation is consistent with the written agreement.
§ 18.122. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
ARC-PA–The Accreditation Review Commission.
Administration–The direct application of a drug, whole blood, blood components, diagnostic procedure or device, whether by injection, inhalation, ingestion, skin application or other means, into the body of a patient.
CAAHEP–The Commission for Accreditation of Allied Health Educational Programs.
CAHEA–The Committee on Allied Health Education and Accreditation.
Device–An instrument or tool necessary in the administration of medication or medical care.
Dispense–To deliver a drug or device to or for an ultimate user for limited or continuing use.
Drug–A term used to describe a medication, device or agent which a physician assistant prescribes or dispenses under § 18.158 (relating to prescribing and dispensing drugs, pharmaceutical aids and devices).
Emergency medical care setting–
(i) A health care setting which is established to provide emergency medical care as its primary purpose.
(ii) The term does not include a setting which provides general or specialized medical services that are not routinely emergency in nature even though that setting provides emergency medical care from time to time.
Medical care facility–An entity licensed or approved to render health care services.
Medical regimen–A therapeutic, corrective or diagnostic measure performed or ordered by a physician, or performed or ordered by a physician assistant acting within the physician assistant’s scope of practice, and in accordance with the written agreement between the supervising physician and the physician assistant.
Medical service–An activity which lies within the scope of the practice of medicine and surgery.
NCCPA–The National Commission on Certification of Physician Assistant.
Order–An oral or written directive for a therapeutic, corrective or diagnostic measure, including a drug to be dispensed for onsite administration in a hospital, medical care facility or office setting.
Physician–A medical doctor or doctor of osteopathic medicine.
Physician assistant–An individual who is licensed as a physician assistant by the Board.
Physician assistant examination–An examination to test whether an individual has accumulated sufficient academic knowledge to qualify for licensure as a physician assistant. The Board recognizes the certifying examination of the NCCPA.
Physician assistant program–A program for the training and education of physician assistants which is recognized by the Board and accredited by the CAHEA, the CAAHEP, ARC-PA or a successor agency.
(i) A written or oral order for a drug or device to be dispensed to or for an ultimate user.
(ii) The term does not include an order for a drug which is dispensed for immediate administration to the ultimate user; for example, an order to dispense a drug to a patient for immediate administration in an office or hospital is not a prescription.
Primary supervising physician–A medical doctor who is registered with the Board and designated in the written agreement as having primary responsibility for directing and personally supervising the physician assistant.
Satellite location–A location, other than the primary place at which the supervising physician provides medical services to patients, where a physician assistant provides medical services.
Substitute supervising physician–A supervising physician who is registered with the Board and designated in the written agreement as assuming primary responsibility for a physician assistant when the primary supervising physician is unavailable.
Supervising physician–Each physician who is identified in a written agreement as a physician who supervises a physician assistant.
(i) Oversight and personal direction of, and responsibility for, the medical services rendered by a physician assistant. The constant physical presence of the supervising physician is not required so long as the supervising physician and the physician assistant are, or can be, easily in contact with each other by radio, telephone or other telecommunications device.
(ii) An appropriate degree of supervision includes:
(A) Active and continuing overview of the physician assistant’s activities to determine that the physician’s directions are being implemented.
(B) Immediate availability of the supervising physician to the physician assistant for necessary consultations.
(C) Personal and regular review within 10 days by the supervising physician of the patient records upon which entries are made by the physician assistant.
Written agreement--The agreement between the physician assistant and supervising physician, which satisfies the requirements of § 18.142 (relating to written agreements).
PHYSICIAN ASSISTANT EDUCATIONAL PROGRAMS
§ 18.131. Recognized educational programs/stan- dards.
(a) The Board recognizes physician assistant educational programs accredited by the American Medical Association’s CAHEA, the CAAHEP, ARC-PA or a successor organization. Information regarding accredited programs may be obtained directly from ARC-PA at its website: www.arc-pa.org
(b) The criteria for recognition by the Board of physician assistant educational programs will be identical to the essentials developed by the various organizations listed in this section or other accrediting agencies approved by the Board.
LICENSURE OF PHYSICIAN ASSISTANTS AND REGISTRATION OF SUPERVISING PHYSICIANS
§ 18.141. Criteria for licensure as a physician assistant.
The Board will approve for licensure as a physician assistant an applicant who:
(1) Satisfies the licensure requirements in § 16.12 (relating to general qualifications for licenses and certificates).
(2) Has graduated from a physician assistant program recognized by the Board.
(3) Has submitted a completed application together with the required fee, under § 16.13 (relating to licensure, certification, examination and registration fees).
(4) Has passed the physician assistant examination.
§ 18.142. Written agreements.
(a) The written agreement required by section 13(e) of the act (63 P. S. § 422.13(e)) satisfies the following requirements. The agreement must:
(1) Identify and be signed by the physician assistant and each physician the physician assistant will be assisting who will be acting as a supervising physician. At least one physician shall be a medical doctor.
(2) Describe the manner in which the physician assistant will be assisting each named physician. The description must list functions to be delegated to the physician assistant.
(3) Describe the time, place and manner of supervision and direction each named physician will provide the physician assistant, including the frequency of personal contact with the physician assistant.
(4) Designate one of the named physicians who shall be a medical doctor as the primary supervising physician.
(5) Require that the supervising physician shall countersign the patient record completed by the physician assistant within a reasonable amount of time. This time period may not exceed 10 days.
(6) Identify the locations and practice settings where the physician assistant will serve.
(b) The written agreement shall be approved by the Board as satisfying the requirements in subsection (a) and as being consistent with relevant provisions of the act and regulations contained in this subchapter.
(c) A physician assistant or supervising physician shall provide immediate access to the written agreement to anyone seeking to confirm the scope of the physician assistant’s authority.
§ 18.143. Criteria for registration as a supervising physician.
(a) The Board will register a supervising physician applicant who:
(1) Possesses a current license without restriction to practice medicine and surgery in this Commonwealth.
(2) Has filed a completed registration form accompanied by the written agreement (see § 18.142 (relating to written agreements)) and the required fee under § 16.13 (relating to licensure, certification, examination and registration fees). The registration requires detailed information regarding the physician’s professional background and specialties, medical education, internship, residency, continuing education, membership in American Boards of medical specialty, hospital or staff privileges and other information the Board may require.
(3) Includes with the registration, a list, identifying by name and license number, the other physicians who are serving as supervising physicians of the designated physician assistant under other written agreements.
(b) If the supervising physician plans to utilize physician assistants in satellite locations, the supervising physician shall provide the Board with supplemental information as set forth in § 18.155 (relating to satellite locations) and additional information requested by the Board directly relating to the satellite location.
(c) The Board will keep a current list of registered supervising physicians. The list will include the physician’s name, the address of residence, current business address, the date of filing, satellite locations if applicable, the names of current physician assistants under the physician’s supervision and the physicians willing to provide substitute supervision.
§ 18.144. Responsibility of primary supervising physician.
A primary supervising physician shall assume the following responsibilities. The supervisor shall:
(1) Monitor the compliance of all parties to the written agreement with the standards contained in the written agreement, the act and this subchapter.
(2) Advise any party to the written agreement of the failure to conform with the standards contained in the written agreement, the act and this subchapter.
(3) Arrange for a substitute supervising physician. (See § 18.154 (relating to substitute supervising physician).)
(4) Review directly with the patient the progress of the patient’s care as needed based upon the patient’s medical condition and prognosis or as requested by the patient.
(5) See each patient while hospitalized at least once.
(6) Provide access to the written agreement upon request and provide clarification of orders and prescriptions by the physician assistant relayed to other health care practitioners.
(7) Accept full professional and legal responsibility for the performance of the physician assistant and the care and treatment of the patients.
§ 18.145. Biennial registration requirements; renewal of physician assistant license.
(a) A physician assistant shall register biennially according to the procedure in § 16.15 (relating to biennial registration; inactive status and unregistered status).
(b) The fee for the biennial registration of a physician assistant license is set forth in § 16.13 (relating to licensure, certification, examination and registration fees).
(c) To be eligible for renewal of a physician assistant license, the physician assistant shall maintain National certification by completing current recertification mechanisms available to the profession and recognized by the Board.
(d) The Board will keep a current list of persons licensed as physician assistants. The list will include:
(1) The name of each physician assistant.
(2) The place of residence.
(3) The current business address.
(4) The date of initial licensure, biennial renewal record and current supervising physician.
PHYSICIAN ASSISTANT UTILIZATION
§ 18.151. Role of physician assistant.
(a) The physician assistant practices medicine with physician supervision. A physician assistant may perform those duties and responsibilities, including the ordering, prescribing, dispensing, and administration of drugs and medical devices, as well as the ordering, prescribing, and executing of diagnostic and therapeutic medical regimens, as directed by the supervising physician.
(b) The physician assistant may provide any medical service as directed by the supervising physician when the service is within the physician assistant’s skills, training and experience, forms a component of the physician’s scope of practice, is included in the written agreement and is provided with the amount of supervision in keeping with the accepted standards of medical practice.
(c) The physician assistant may pronounce death, but not the cause of death, and may authenticate with the physician assistant’s signature any form related to pronouncing death. If the attending physician is not available, the physician assistant shall notify the county coroner. The coroner has the authority to release the body of the deceased to the funeral director.
(d) The physician assistant may authenticate with the physician assistant’s signature any form that may otherwise be authenticated by a physician’s signature as permitted by the supervising physician, State or Federal law and facility protocol, if applicable.
(e) The physician assistant shall be considered the agent of the supervising physician in the performance of all practice-related activities including the ordering of diagnostic, therapeutic and other medical services.
§ 18.152. Prohibitions.
(a) A physician assistant may not:
(1) Provide medical services except as described in the written agreement.
(2) Prescribe or dispense drugs except as described in the written agreement.
(3) Maintain or manage a satellite location under § 18.155 (relating to satellite locations) unless the maintenance or management is registered with the Board.
(4) Independently practice or bill patients for services provided.
(5) Independently delegate a task specifically assigned to him by the supervising physician to another health care provider.
(6) List his name independently in a telephone directory or other directory for public use in a manner which indicates that he functions as an independent practitioner.
(7) Perform acupuncture except as permitted by section 13(k) of the act (63 P. S. § 422.13(k)).
(8) Perform a medical service without the supervision of a supervising physician.
(b) A supervising physician may not:
(1) Permit a physician assistant to engage in conduct proscribed in subsection (a).
(2) Have primary responsibility for more than two physician assistants.
§ 18.153. Executing and relaying medical regimens.
(a) A physician assistant may execute a written or oral order for a medical regimen or may relay a written or oral order for a medical regimen to be executed by a health care practitioner subject to the requirements of this section.
(b) As provided for in the written agreement, the physician assistant shall report orally or in writing, to a supervising physician, within 36 hours, those medical regimens executed or relayed by the physician assistant while the supervising physician was not physically present, and the basis for each decision to execute or relay a medical regimen.
(c) The physician assistant shall record, date and authenticate the medical regimen on the patient’s chart at the time it is executed or relayed. When working in a medical care facility, a physician assistant may comply with the recordation requirement by directing the recipient of the order to record, date and authenticate that the recipient received the order, if this practice is consistent with the medical care facility’s written policies. The supervising physician shall countersign the patient record within a reasonable time not to exceed 10 days, unless countersignature is required sooner by regulation, policy within the medical care facility or the requirements of a third-party payor.
(d) A physician assistant or supervising physician shall provide immediate access to the written agreement to anyone seeking to confirm the physician assistant’s authority to relay a medical regimen or administer a therapeutic or diagnostic measure.
§ 18.154. Substitute supervising physician.
(a) If the primary supervising physician is unavailable to supervise the physician assistant, the primary supervising physician may not delegate patient care to the physician assistant unless appropriate arrangements for substitute supervision are in the written agreement and the substitute physician is registered as a supervising physician with the Board.
(b) It is the responsibility of the substitute supervising physician to ensure that supervision is maintained in the absence of the primary supervising physician.
(c) During the period of supervision by the substitute supervising physician, the substitute supervising physician retains full professional and legal responsibility for the performance of the physician assistant and the care and treatment of the patients treated by the physician assistant.
(d) Failure to properly supervise may provide grounds for disciplinary action against the substitute supervising physician.
§ 18.155. Satellite locations.
(a) Registration of satellite location. A physician assistant may not provide medical services at a satellite location unless the supervising physician has filed a registration with the Board.
(b) Contents of statement. A separate statement shall be made for each satellite location. The statement must demonstrate that:
(1) The physician assistant will be utilized in an area of medical need.
(2) There is adequate provision for direct communication between the physician assistant and the supervising physician and that the distance between the location where the physician provides services and the satellite location is not so great as to prohibit or impede appropriate support services.
(3) The supervising physician shall review directly with the patient the progress of the patient’s care as needed based upon the patient’s medical condition and prognosis or as requested by the patient.
(4) The supervising physician will visit the satellite location at least once every 10 days and devote enough time onsite to provide supervision and personally review the records of selected patients seen by the physician assistant in this setting. The supervising physician shall notate those patient records as reviewed.
(c) Failure to comply with this section. Failure to maintain the standards required for a satellite location may result not only in the loss of the privilege to maintain a satellite location but also may result in disciplinary action against the physician assistant and the supervising physician.
§ 18.156. Monitoring and review of physician assistant utilization.
(a) Representatives of the Board will be authorized to conduct scheduled and unscheduled onsite inspections of the locations where the physician assistants are utilized during the supervising physician’s office hours to review the following:
(1) Supervision of the physician assistant. See §§ 18.144 and 18.154 (relating to responsibility of primary supervising physician; and substitute supervising physician).
(2) Presence of the written agreement and compliance with its terms. See § 18.142 (relating to written agreements).
(3) Utilization in conformity with the act, this sub- chapter and the written agreement.
(4) Appropriate identification of physician assistant. See § 18.171 (relating to physician assistant identification).
(5) Compliance with licensure and registration requirements. See §§ 18.141 and 18.145 (relating to criteria for licensure as a physician assistant; and biennial registration requirements; renewal of physician assistant license).
(6) Maintenance of records evidencing patient and supervisory contact by the supervising physician.
(b) Reports shall be submitted to the Board and become a permanent record under the supervising physician’s registration. Deficiencies reported will be reviewed by the Board and may provide a basis for loss of the privilege to maintain a satellite location and disciplinary action against the physician assistant and the supervising physician.
(c) The Board reserves the right to review physician assistant utilization without prior notice to either the physician assistant or the supervising physician. It is a violation of this subchapter for a supervising physician or a physician assistant to refuse to comply with the request by the Board for the information in subsection (a).
(d) Additional inspections, including follow-up inspections may be conducted if the Board has reason to believe that a condition exists which threatens the public health, safety or welfare.
§ 18.157. Administration of controlled substances and whole blood and blood components.
(a) In a hospital, medical care facility or office setting, the physician assistant may order or administer, or both, controlled substances and whole blood and blood components if the authority to order and administer these medications and fluids is expressly set forth in the written agreement.
(b) The physician assistant shall comply with the minimum standards for ordering and administering controlled substances specified in § 16.92 (relating to prescribing, administering and dispensing controlled substances).
§ 18.158. Prescribing and dispensing drugs, pharmaceutical aids and devices.
(a) Prescribing, dispensing and administration of drugs.
(1) The supervising physician may delegate to the physician assistant the prescribing, dispensing and administering of drugs and therapeutic devices.
(2) A physician assistant may not prescribe or dispense Schedule I controlled substances as defined by section 4 of The Controlled Substances, Drug, Device, and Cosmetic Act (35 P. S. § 780-104).
(3) A physician assistant may prescribe a Schedule II controlled substance for initial therapy, up to a 72-hour dose. The physician assistant shall notify the supervising physician of the prescription as soon as possible, but in no event longer than 24 hours from the issuance of the prescription. A physician assistant may write a prescription for a Schedule II controlled substance for up to a 30-day supply if it was approved by the supervising physician for ongoing therapy. The prescription must clearly state on its face that it is for initial or ongoing therapy.
(4) A physician assistant may only prescribe or dispense a drug for a patient who is under the care of the physician responsible for the supervision of the physician assistant and only in accordance with the supervising physician’s instructions and written agreement.
(5) A physician assistant may request, receive and sign for professional samples and may distribute professional samples to patients.
(6) A physician assistant authorized to prescribe or dispense, or both, controlled substances shall register with the Drug Enforcement Administration (DEA).
(b) Prescription blanks. The requirements for prescription blanks are as follows:
(1) Prescription blanks must bear the license number of the physician assistant and the name of the physician assistant in a printed format at the heading of the blank. The supervising physician must also be identified as required in § 16.91 (relating to identifying information on prescriptions and orders for equipment and service).
(2) The signature of a physician assistant shall be followed by the initials ‘PA-C’ or similar designation to identify the signer as a physician assistant. When appropriate, the physician assistant’s DEA registration number must appear on the prescription.
(3) The supervising physician is prohibited from presigning prescription blanks.
(4) The physician assistant may use a prescription blank generated by a hospital provided the information in paragraph (1) appears on the blank.
(c) Inappropriate prescription. The supervising physician shall immediately advise the patient, notify the physician assistant and, in the case of a written prescription, advise the pharmacy if the physician assistant is prescribing or dispensing a drug inappropriately. The supervising physician shall advise the patient and notify the physician assistant to discontinue using the drug and, in the case of a written prescription, notify the pharmacy to discontinue the prescription. The order to discontinue use of the drug or prescription shall be noted in the patient’s medical record by the supervising physician.
(d) Recordkeeping requirements. Recordkeeping requirements are as follows:
(1) When prescribing a drug, the physician assistant shall keep a copy of the prescription, including the number of refills, in a ready reference file, or record the name, amount and doses of the drug prescribed, the number of refills, the date of the prescription and the physician assistant’s name in the patient’s medical records.
(2) When dispensing a drug, the physician assistant shall record the physician assistant’s name, the name of the medication dispensed, the amount of medication dispensed, the dose of the medication dispensed and the date dispensed in the patient’s medical records.
(3) The physician assistant shall report, orally or in writing, to the supervising physician within 36 hours, a drug prescribed or medication dispensed by the physician assistant while the supervising physician was not physically present, and the basis for each decision to prescribe or dispense in accordance with the written agreement.
(4) The supervising physician shall countersign the patient record within 10 days.(5) The physician assistant and the supervising physician shall provide immediate access to the written agreement to anyone seeking to confirm the physician assistant’s authority to prescribe or dispense a drug. The written agreement must list the categories of drugs which the physician assistant is not permitted to prescribe.
(e) Compliance with regulations relating to prescribing, administering, dispensing, packaging and labeling of drugs. A physician assistant shall comply with §§ 16.92–16.94 (relating to prescribing, administering and dispensing controlled substances; packaging; and labeling of dispensed drugs) and Department of Health regulations in 28 Pa. Code §§ 25.51–25.58 (relating to prescriptions) and regulations regarding packaging and labeling dispensed drugs. See § 16.94 and 28 Pa. Code §§ 25.91–25.95 (relating to labeling of drugs, devices and cosmetics).
§ 18.159. Medical records.
The supervising physician shall timely review, not to exceed 10 days, the medical records prepared by the physician assistant to ensure that the requirements of § 16.95 (relating to medical records) have been satisfied.
MEDICAL CARE FACILITIES AND EMERGENCY MEDICAL SERVICES
§ 18.161. Physician assistant employed by medical care facilities.
(a) A physician assistant may be employed by a medical care facility, but shall comply with the requirements of the act and this subchapter.
(b) The physician assistant may not be responsible to more than three supervising physicians in a medical care facility.
(c) This subchapter does not require medical care facilities to employ physician assistants or to permit their utilization on their premises. Physician assistants are permitted to provide medical services to the hospitalized patients of their supervising physicians if the medical care facility permits it.
(d) Physician assistants granted privileges by, or practicing in, a medical care facility shall conform to policies and requirements delineated by the facility.
§ l8.162. Emergency medical services.
(a) A physician assistant may only provide medical service in an emergency medical care setting if the physician assistant has training in emergency medicine, functions within the purview of the physician assistant’s written agreement and is under the supervision of the supervising physician.
(b) A physician assistant licensed in this Commonwealth or licensed or authorized to practice in any other state who is responding to a need for medical care created by a declared state of emergency or a state or local disaster (not to be defined as an emergency situation which occurs in the place of one’s employment) may render care consistent with relevant standards of care.
IDENTIFICATION AND NOTICE RESPONSIBILITIES
§ 18.171. Physician assistant identification.
(a) A physician assistant may not render medical services to a patient until the patient or the patient’s legal guardian has been informed that:
(1) The physician assistant is not a physician.
(2) The physician assistant may perform the service required as the agent of the physician and only as directed by the supervising physician.
(3) The patient has the right to be treated by the physician if the patient desires.
(b) It is the supervising physician’s responsibility to be alert to patient complaints concerning the type or quality of services provided by the physician assistant.
(c) In the supervising physician’s office and satellite locations, a notice plainly visible to patients shall be posted in a prominent place explaining that a ‘physician assistant’ is authorized to assist a physician in the provision of medical care and services. The supervising physician shall display the registration to supervise in the office. The physician assistant’s license shall be prominently displayed at any location at which the physician assistant provides services. Duplicate licenses may be obtained from the Board if required.
(d) The physician assistant shall wear an identification tag which uses the term ‘Physician Assistant’ in easily readable type. The tag shall be conspicuously worn.
§ 18.172. Notification of changes in employment.
(a) The physician assistant is required to notify the Board, in writing, of a change in or termination of employment or a change in mailing address within 15 days. Failure to notify the Board, in writing, of a change in mailing address may result in failure to receive pertinent material distributed by the Board. The physician assistant shall provide the Board with the new address of residence, address of employment and name of registered supervising physician.
(b) The supervising physician is required to notify the Board, in writing, of a change or termination of supervision of a physician assistant within 15 days.
(c) Failure to notify the Board of changes in employment or a termination in the physician/physician assistant relationship is a basis for disciplinary action against the physician’s license, supervising physician’s registration and the physician assistant’s license.
§ 18.181. Disciplinary and corrective measures.
(a) A physician assistant who engages in unprofessional conduct is subject to disciplinary action under section 41 of the act (63 P. S. § 422.41). Unprofessional conduct includes the following:
(1) Misrepresentation or concealment of a material fact in obtaining a license or a reinstatement thereof.
(2) Commission of an offense against the statutes of the Commonwealth relating to the practice of physician assistants or regulations adopted thereunder.
(3) Commission of an act involving moral turpitude, dishonesty or corruption when the act directly or indirectly affects the health, welfare or safety of citizens of this Commonwealth. If the act constitutes a crime, conviction thereof in a criminal proceeding may not be a condition precedent to disciplinary action.
(4) Conviction of a felony or conviction of a misdemeanor relating to a health profession or receiving probation without verdict, disposition in lieu of trial or an accelerated rehabilitative disposition in the disposition of felony charges, in the courts of the Commonwealth, a Federal court or a court of another State, territory or country.
(5) Misconduct in practice as a physician assistant or performing tasks fraudulently, beyond its authorized scope, with incompetence, or with negligence on a particular occasion or negligence on repeated occasions.
(6) Performance of tasks as a physician assistant while the ability to do so is impaired by alcohol, drugs, physical disability or mental instability.
(7) Impersonation of a licensed physician or another licensed physician assistant.
(8) Offer, undertake or agree to cure or treat disease by a secret method, procedure, treatment or medicine; the treating, prescribing for a human condition, by a method, means or procedure which the physician assistant refuses to divulge upon demand of the Board; or use of methods or treatment which are not in accordance with treatment processes accepted by a reasonable segment of the medical profession.
(9) Violation of a provision of this subchapter fixing a standard of professional conduct.
(10) Continuation of practice while the physician assistant’s license has expired, is not registered or is suspended or revoked.
(11) Delegating a medical responsibility to a person when the physician assistant knows or has reason to know that the person is not qualified by training, experience, license or certification to perform the delegated task.
(12) The failure to notify the supervising physician that the physician assistant has withdrawn care from a patient.
(b) The Board will order the emergency suspension of the license of a physician assistant who presents an immediate and clear danger to the public health and safety, as required by section 40 of the act (63 P. S. § 422.40).
(c) The license of a physician assistant shall automatically be suspended, under conditions in section 40 of the act.
(d) The Board may refuse, revoke or suspend a physician’s registration as a supervising physician for engaging in any of the conduct proscribed of Board-regulated practitioners in section 41 of the act.
[Pa.B. Doc. No. 06-2263. Filed for public inspection November 17, 2006, 9:00 a.m.]