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Indiana Professional Licensing Agency

PLA > Professions > Physician Assistant Committee > Applications & Instructions > Application and Instructions for Licensure as a Physician Assistant Application and Instructions for Licensure as a Physician Assistant

Physician Assistant Licensure Application

Criminal Background Check Information
State Verification Form

Sample Supervisory Agreement

Frequently Asked Questions

CONTACT INFORMATION
Indiana Professional Licensing Agency
Physician Assistant Committee
402 West Washington Street, Room W072
Indianapolis, IN 46204
E-mail:  pla3@pla.in.gov
(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 statutes and rules on our website.  For your convenience you may click on the following link:  STATUTES AND RULES

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.

If you have not secured employment, you do not need to complete or send in the Supervising Physician page of the application, nor do you need to submit a supervising agreement.  A license may be issued without both.  Once you obtain employment you must then complete a change/addition application, submit it with payment and a supervising agreement.  You will not be able to practice until we have a supervising agreement on file.  If you have any questions concerning this please feel free to contact the Committee.

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.

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.

Please note that we cannot accept dark copies of documents.  Documents are all scanned and if they are dark they are not legible.  

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.  An affidavit is not needed if you responded to Question #12 regarding employment history.

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.

CRIMINAL BACKGROUND CHECKS

Any physician seeking initial licensure are required to  submit to fingerprinting and a national criminal background check by the Indiana State Police.  The individual applicant will be responsible for the cost of the background check.  The backgrounds must be done by the state approved vendor and any checks done outside the chain of command will not be accepted.  Information on how to be fingerprinted and a list of frequently asked questions, go to criminal background check information.

OFFICIAL TRANSCRIPT
Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been confirmed.

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:  nccpa@nccpa.net
Website:  http://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.  Many states use their own computer generated document, in lieu of our form, which is acceptable.

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.  The agreement must also indicate all locations where the PA and the supervising physician may practice.  Agreements also need to include a 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

If the physician assistant 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.  

If you have not secured employment, you will not need to submit a supervising agreement.  Once you obtain employment, you will need to complete a change/addition application and submit it with the fee and a supervising agreement. 

PRESCRIPTIVE AUTHORITY
Physician Assistants who have practiced less than one year and 1,800 hours, are eligible only to prescribe legend drugs (non-controlled substances).  You must submit the application, proof of pharmacology and information in the practice agreement regarding the classifications of legend drugs you are eligible to prescribe.  To prescribe controlled substances, you must submit proof of the work experience along with the Controlled Substance Registration.

All prescriptive authority applications must be reviewed by the Physician Assistance Committee and the Medical Licensing Board.

CHART REVIEW & SUPERVISION

- The review of patient encounters will require review within 72 hours for the following:

• 100% of the charts for the first year of employment
• 50% for the second year of employment
• 25% for the third year of employment
• For the first year in which a physician assistant obtains authority to prescribe controlled substances, 100% of the patient records for which is a controlled substance is being dispensed or prescribed.  

If a physician assistant changes supervising physicians but remains in the same practice specialty, the schedule of chart review does not start over. However, if the PA is 
employed in a different practice specialty, the full schedule of chart review listed above must be followed.

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 in revision process to reflect this.

TEMPORARY PERMIT
Your application file must be complete and pending Committee review before a temporary permit may be issued.  If you wish to practice while waiting for your application file to be reviewed you must apply for and obtain a temporary permit. 

According to IC 25-27.5-4-4
(a) The committee may grant a temporary license to an applicant who meets all qualifications for licensure (including the passage of the examination) and is awaiting the next scheduled meeting of the committee.
(b) A temporary license is valid until the committee makes a final decision on the applicant's request for a license.            

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.

POCKET CARD 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.