Section 844IAC4-4.5-7. Application for a license

   (a) A person seeking licensure to practice medicine or osteopathic medicine shall file an application on a form supplied by the board and submit the fees required by 844 IAC 4-2-2.

  (b) The applicant for a license shall provide the following:

(1) Where the name on any document differs from the applicant's name, a notarized or certified copy of a marriage certificate or legal proof of name change must be submitted with the application.

(2) One (1) recent passport-type photograph of the applicant, taken within eight (8) weeks prior to filing of the application.

(3) A certified copy of the original medical school or osteopathic medical school diploma. The following are requirements in the event that such diploma has been lost or destroyed:

(A) The applicant shall submit, in lieu thereof, a statement under the signature and seal of the dean of the medical school or osteopathic medical school or college from which the applicant graduated, stating that the applicant has satisfactorily completed the prescribed course of study, the actual degree conferred, and the date of graduation.

(B) The applicant shall submit an affidavit fully and clearly stating the circumstances under which his or her diploma was lost or destroyed.

(C) In exceptional circumstances, the board may accept, in lieu of a diploma or certified copy thereof, other types of evidence, which establish that the applicant received a medical school or osteopathic medical school or college diploma and completed all academic requirements relating thereto.

(4) If the applicant is the graduate of a school of medicine or osteopathic medicine in the United States, its possessions, or Canada, an original transcript of the applicant's medical education, including the degree conferred and the date the degree was conferred must be submitted. If the original transcript is in a language other than English, the applicant must include a certified translation of the transcript.

(5) If the applicant is a graduate of a school of medicine or osteopathic medicine outside the United States, its possessions, or Canada, the applicant must submit an original transcript of the applicant's medical education, including the degree conferred and the date the degree was conferred. If the original transcript is in a language other than English, the applicant must include a certified translation of the transcript. If an original transcript is not available, the applicant must submit the following:

(A) A notarized or certified copy of the original medical school or osteopathic medical school transcript, which must include the degree conferred and the date the degree was conferred.

(B) An affidavit fully and clearly stating the reasons that an original transcript is not available.

(6) If the applicant has been convicted of a criminal offense (excluding minor traffic violations), the applicant shall submit a notarized statement detailing all criminal offenses (excluding minor traffic violations) for which the applicant has been convicted. This notarized statement must include the following:

(A) The offense of which the applicant was convicted.

(B) The court in which the applicant was convicted.

(C) The cause number under which the applicant was convicted.

(D) The penalty imposed by the court.

(7) If the applicant is a graduate of a school of medicine or osteopathic medicine outside the United States, its possessions, or Canada, the applicant must submit a notarized copy of a certificate issued to the applicant by the Educational Commission on Foreign Medical Graduates.

(8) All applicants who are now, or have been, licensed to practice any health profession in another state must submit verification of license status. This information must be sent by the state that issued the license directly to the Indiana board.

(9) The applicant shall submit a self-query form completed by the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank.

(10) All information on the application shall be submitted under oath or affirmation, subject to the penalties for perjury.

(Medical Licensing Board of Indiana; 844 IAC 4-4.5-7; filed Sep 3, 2002, 3:38 p.m.: 26 IR 29; readopted filed Oct 10, 2008, 8:57 a.m.: 20081105-IR-844080339RFA; readopted filed Dec 2, 2014, 10:09 a.m.: 20141231-IR-844140391RFA)