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Indiana Professional Licensing Agency

PLA > Professions > Physician Assistant Committee > Applications & Instructions > Instructions for Change or Addition of Supervising Physician Instructions for Change or Addition of Supervising Physician

 

Change and Addition of Supervising Physician Application

Before completing and submitting your application, please read all instructions.  If you have any questions please contact Professional Licensing Agency.

Professional Licensing Agency
402 West Washington Street
Room W072
Indianapolis, IN 46204
(317) 234-2060
email: pla3@pla.IN.gov

 

CORRESPONDENCE

Address all correspondence regarding your application to the PHYSICIAN ASSISTANT COMMITTEE. Please be sure to include an email address as all communication regarding status updates will be mailed via email.

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 Indiana Code. Disclosure is mandatory, and this record cannot be processed without it.

REQUIREMENTS

APPLICATION. The Physician Assistant and the Supervising Physician must complete, date and sign the enclosed application and return it to the Professional Licensing Agency along with the items listed below:

FEE:  The fee for the change and addition application is $50.00.  Please make all checks payable to the Professional Licensing Agency.  All fees are non-refundable.

  • 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 change/addition 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.     Sample Agreement or Sample Agreement for a PA with prescriptive authority

 

          In accordance with IC 25-27.5-6-2, a physician may  have supervising agreements with more than two (2) physician assistants, however may NOT supervise more than two (2) physician assistants at any given time.  The application is currently in revision process to reflect this.