Section 844IAC15-1-3. Licensure; application

   (a) The application for licensure of an anesthesiologist assistant must be made upon forms supplied by the board.

  (b) Each application for licensure as an anesthesiologist assistant shall include the following information:

(1) An official transcript sent directly from the institution of higher learning where the applicant received a baccalaureate degree.

(2) An official transcript sent directly from the approved program where the applicant received a degree, including the degree conferred and the date of graduation.

(3) Verification from NCCAA of the applicant's certification status.

(4) If 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.

(5) 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) An applicant who currently holds, or has previously held, a license, certification, or registration issued by another state to practice any health profession must request verification of license status from the state that issued that license, certification, or registration. The verification must be sent directly to the board from the agency that issued the license, certification, or registration. Official electronic verification will also be accepted.

  (e) Each applicant for licensure as an anesthesiologist assistant shall submit an executed authorization and release form supplied by the board that:

(1) authorizes the board 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 person, corporation, partnership, association, organization, institute, forum, or officer thereof, to furnish, provide, and supply to the board all relevant documents, records, or other information pertaining to the applicant; and

(3) releases the board, or any of its authorized representatives, and any person, corporation, partnership, association, organization, institute, forum, or officer thereof, from any and all liability regarding such inspection, review, receipt, furnishing, or supplying of any such information.

  (f) Application forms submitted to the board must be complete. Except as otherwise required by this section, all supporting documents required by the application must be submitted with the application. (Medical Licensing Board of Indiana; 844 IAC 15-1-3; filed Feb 26, 2016, 9:09 a.m.: 20160323-IR-844150300FRA)