PHYSICIAN ASSISTANT APPLICATION
INSTRUCTIONS AND INFORMATION
PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION. If after reading the instructions you have questions please contact our office.
CONTACT INFORMATION
Indiana Professional Licensing Agency
Physician Assistant Committee
402 West Washington Street, Room W072
Indianapolis, IN 46204
E-mail:
(317) 234-2060
(317) 233-4236(fax)
ALL APPLICATIONS NEED TO BE REVIEWED BY THE PHYSICIAN ASSISTANT COMMITTEE PRIOR TO ISSUANCE.
STATUTES AND RULES
You may view the statute and rules on our website. For your convenience you may click on the following link: http://www.in.gov/pla/3351.htm
NOTARIZED COPY INFORMATION
When submitting a notarized copy of an original document, the notary MUST make a statement to the fact that the notary has seen the original document. If this is not done the document will NOT be accepted.
THE FAIR INFORMATION PRACTICE ACT
In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record. Your examination scores and grade transcripts are confidential except in circumstances where their release is required by law, in which case you will be notified. Your Social Security Number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.
LIMIT OF PHYSICIAN ASSISTANTS
In accordance with IC 25-27.5-6-2, a physician may supervise not more than two (2) physician assistants.
DOCUMENTS REQUIRED FOR LICENSURE
(To reinforce the notarized copy information: When submitting a notarized copy of an original document, the notary MUST make a statement to the fact that the notary has seen the original document. If this is not done the document will NOT be accepted)
· COMPLETED APPLICATION
You and your supervising physician must complete, date and sign the application for licensure. All information must be completed on the application or have N/A for not applicable. An email address is mandatory. All correspondence regarding the status of your application will be sent via email, as well as all future board newsletters and license renewal information.
· PHOTOGRAPH
Submit one (1) passport quality photo taken within the past eight (8) weeks.
· APPLICATION FEE
Please submit an application fee in the amount of $100.00 payable to Professional Licensing Agency. All fees are non-refundable and non-transferable.
· POSITIVE RESPONSES
If you have answered any of the questions on the application “yes” you must submit a NOTARIZED AFFIDAVIT detailing the occurrence/situation, the outcome, date of occurrence, if it is a malpractice payment include the amount paid in your behalf.
If applicable please submit copies of all court documents and/or arrest records. Letters from attorneys or insurance companies are not accepted in lieu of your statement; however they may be included with your statement.
· OFFICIAL TRANSCRIPT
Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been conferred.
· DIPLOMA
Submit a notarized copy of your diploma.
· SCORE REPORT
You must request that your official score report be sent directly to Professional Licensing Agency from the NCCPA.
National Commission on Certification
of Physician Assistants
12000 Findley Road, Suite 200
Duluth, GA 30097
(678) 417-8100
(678) 417-8135 (fax)
Email:
Website: www.nccpa.net
· NCCPA CERTIFICATE
Submit a notarized copy of your current NCCPA certificate.
· VERIFICATION OF STATE LICENSURE(S)
You must request a “License Verification or Letter of Good Standing” from each State/Country in which you currently are or have ever been licensed, certified, or registered in any regulated health profession or occupation.
This includes all licenses, etc., that are active, expired, inactive, retired, delinquent etc. In addition to any physician assistant license/certification etc., this also pertains to any professional health license such as an EMT, nurse, pharmacist, etc.
You will need to print off the verification form and contact the appropriate entities/states regarding their process. They may charge a fee for this service. They will need to complete the verification and mail it directly to our office.
We do not accept web verifications; the verification must come directly from the State in which you were licensed.
· NAME CHANGE
Submit a notarized copy of a legal name change document (ex: marriage certificate/divorce decree) if documents you are submitting contain a different name than what is listed on your application for licensure.
· SUPERVISORY AGREEMENT
The supervising physician shall submit a description of the exact privileges and tasks the physician assistant shall be performing under the physician’s supervision. The supervising agreement shall be specific to the physician assistant being hired “i.e. John Brown, PA will be responsible for…” In addition give a detailed description of the process maintained for evaluation of the physician assistant’s performance. Also include a description of procedures for dealing with emergencies. The supervising agreement must be on letterhead and signed by both the physician and physician assistant.
If the physician assistant has been granted prescriptive authority or is applying for prescriptive authority in conjunction with this initial application, the supervising agreement must also include a list of classifications of medications the physician assistant is delegated to prescribe. Description of protocols used in the practice. Protocols to be used for physician assistant prescribing may include clinical practice guidelines, reference texts, or other sources.
The application for prescriptive authority may be found at http://www.in.gov/pla/pa.htm
· TEMPORARY LICENSE
In order to practice in the State of Indiana as a physician assistant before you are issued a full license, you must hold a valid temporary license.
According to IC 25-27.5-4-4
(a) The committee may grant a temporary license to an applicant who:
(1) meets the qualifications for licensure under section 1 of this chapter except:
(A) for the taking of the next scheduled NCCPA examination; or
(B) if the applicant has taken the NCCPA examination and is awaiting the results; or
(2) meets the qualifications under section 1 of this chapter but is awaiting the
next scheduled meeting of the committee.
(b) A temporary license is valid until:
(1) the results of an applicant’s examination are available; and
(2) the committee makes a final decision on the applicant’s request for a
license.
· TEMPORARY PERMIT FEE
If applying for a temporary permit you must also submit along with the application fee, a payment of $50.00 made payable to Professional Licensing Agency.
All fees are non refundable and non transferable.
· RENEWAL INFORMATION
All physician assistant licenses expire on June 30 of the even years regardless of when they are issued. If you are approaching the next renewal date, you might want to consider holding off on licensure until after that time if you want to avoid a renewal fee. The cost to renew a physician assistant license is $50.
· RENEWAL INFORMATION
As a result of recent cost cutting measures and continued efforts to ensure taxpayer savings during this tough economic climate, we will no longer be printing and/or mailing wall licenses and pocket cards to individual licensees upon issuance of a license. Once your license is issued, you will be notified via email of the license number and instructions on how you may purchase a wall certificate or pocket license.