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Indiana Professional Licensing Agency

PLA > Professions > Medical Licensing Board of Indiana > Applications for Licensure > Limited Scope Temporary Medical Permit Limited Scope Temporary Medical Permit

Application for a Non-Renewable Limited Scope Temporary Medical Permit

The Non-Renewable limited scope temporary medical permit shall be limited to a specific activity, function, series of events or purpose, and to a specific geographic area within the state, which limitations shall be stated on the face of the permit.

Note: This permit is valid for a non-renewable period of not more than thirty (30) days for each specific activity, function, series of events or purpose.

Documents Required for Licensure

  1. Completed Application - Please be specific when completing the job specification portion of the application.
  2. Photograph - passport quality photo taken within the past eight (8) weeks.
  3. Application Fee - $100 in the form of a check or money order to the Indiana Professional Licensing Agency.
  4. Proof of Graduation -
    • Official Transcript – An official transcript of grades from the medical/osteopathic school, confirming medical degree.  Transcripts must come directly from the school in an unopened envelope.  Graduates of foreign medical schools must submit notarized copies of all subjects and grades (mark sheets).  Include official translation if not in English.
    • Degree – A notarized copy of your medical/osteopathic degree.  Include official translation if not in English.
  5. Proof of Current License - Provide proof of current licensure in another state. A notarized copy of your current license (billfold license or pocketcard) which shows your license number.

Positive Response

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 the amount paid in your behalf.  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.