Section 844IAC2.2-2-1. Applications

   (a) The application for licensure of a physician assistant must be made upon forms supplied by the committee.

  (b) Each application for licensure as a physician assistant or for a temporary permit shall include all of the following information:

(1) Complete names, address, and telephone number of the physician assistant.

(2) Satisfactory evidence of the following:

(A) Completion of an approved educational program.

(B) Passage of the Physician Assistant National Certifying Examination administered by the NCCPA.

(C) A current NCCPA certificate.

(D) Official transcripts or a notarized copy of transcripts or a notarized copy of CE certificates indicating completion of thirty (30) contact hours of pharmacology.

(E) A letter signed by an employer, past or present, listing the time frame of full-time employment resulting in one thousand eight hundred (1,800) hours in a twelve (12) month period.

(F) Must possess a current Indiana physician assistant license or have submitted an application in conjunction with prescribing authority application.

(3) All names used by the physician assistant, explaining the reason for such name change or use.

(4) The date and place of birth of the physician assistant and age at the time of application.

(5) Citizenship and visa status, if applicable.

(6) Whether the physician assistant has been licensed, certified, or registered in any other jurisdiction and, if so, the dates thereof.

(7) Whether the physician assistant has had disciplinary action taken against the license, certificate, or registration by the licensing or regulatory agency of any other state or jurisdiction and the details and dates thereof.

(8) A complete listing of all places of employment, including:

(A) the name and address of the employers;

(B) the dates of each employment; and

(C) employment responsibilities held or performed;

that the applicant has had since becoming a physician assistant in any state or jurisdiction.

(9) Whether the physician assistant is, or has been, addicted to, or is chemically dependent upon, any narcotic drugs, alcohol, or other drugs and, if so, the details thereof.

(10) Whether the applicant has been denied licensure, certification, approval, or registration as a physician assistant by any other state or jurisdiction and, if so, the details thereof, including the following:

(A) The name and location of the state or jurisdiction denying:

(i) licensure;

(ii) certification;

(iii) approval; or

(iv) registration.

(B) The date of the denial.

(C) The reasons relating to the denial.

(11) Whether the physician assistant has been convicted of, or pleaded guilty to, any violation of federal, state, or local law relating the:

(A) use;

(B) manufacturing;

(C) distributing;

(D) sale;

(E) dispensing; or

(F) possession;

of controlled substances or of drug addiction and, if so, all of the details relating thereto.

(12) Whether the physician assistant has been convicted of, or pleaded guilty to, any federal or state criminal offense, felony, or misdemeanor, except for traffic violations that resulted only in fines and, if so, all of the details thereto.

(13) Whether the physician assistant was denied privileges in any hospital or health care facility, or had such privileges revoked, suspended, or subjected to any restriction, probation, or other type of discipline or limitation, and, if so, all of the details relating thereto, including the:

(A) name and address of the hospital or health care facility;

(B) date of the action; and

(C) reasons therefor.

(14) Whether the physician assistant has ever been admonished, censured, reprimanded, or requested to withdraw, resign, or retire from any hospital or health care facility in which the physician assistant was employed, worked, or held privileges.

(15) Whether the physician assistant has had any malpractice judgments entered against him or her or settled any malpractice action or cause of action and, if so, a complete, detailed description of the facts and circumstances relating thereto.

(16) One (1) passport-type photo taken of the applicant within the last eight (8) weeks.

  (c) All information in the application shall be submitted under oath or affirmation, subject to the penalties of perjury.

  (d) Each applicant for licensure as a physician assistant shall submit an executed authorization and release form supplied by the committee that:

(1) authorizes the committee or any of its authorized representatives to inspect, receive, and review all documents, records, or other information pertaining to the applicant;

(2) authorizes and directs any:

(A) person;

(B) corporation;

(C) partnership;

(D) association;

(E) organization;

(F) institute;

(G) forum; or

(H) officer thereof;

to furnish, provide, and supply to the committee all relevant documents, records, or other information pertaining to the applicant; and

(3) releases the committee, or any of its authorized representatives, and any:

(A) person;

(B) corporation;

(C) partnership;

(D) association;

(E) organization;

(F) institute;

(G) forum; or

(H) officer thereof;

from any and all liability regarding such inspection, review, receipt, furnishing, or supply of any such information.

  (e) Application forms submitted to the committee must be complete. All supporting documents required by the application must be submitted with the application.

  (f) Applicants for a temporary permit to practice as a physician assistant while waiting to take the examination or awaiting results of the examination must submit all requirements of subsection (b), except for subsection (b)(2)(B) and (b)(2)(C), in order to apply for a temporary permit.

  (g) A temporary permit becomes invalid if the temporary permit holder fails to sit or fails to register for the next available examination.

  (h) Prior to beginning practice as a physician assistant, the physician assistant must submit a supervisory agreement to the committee, which must be approved by the board. The supervisory agreement must:

(1) be submitted on employer's letterhead;

(2) be written specifically for the applicant; and

(3) contain the original signature of both the applicant and supervising physician and the date signed.

(Medical Licensing Board of Indiana; 844 IAC 2.2-2-1; filed May 26, 2000, 8:52 a.m.: 23 IR 2498; errata filed Sep 21, 2000, 3:21 p.m.: 24 IR 382; filed Jan 2, 2003, 10:38 a.m.: 26 IR 1558; filed Apr 6, 2010, 2:52 p.m.: 20100505-IR-844090164FRA) NOTE: Expiration postponed by Executive Order #09-12, posted at 20100113-IR-GOV100002EOA.