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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

 

INSTRUCTIONS FOR NON-RENEWABLE LIMITED SCOPE TEMPORARY MEDICAL PERMIT

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION.  If after reading the instructions you have questions please contact our office.

CONTACT INFORMATION
Indiana Professional Licensing Agency
Medical Licensing Board
402 W. Washington Street, Room W072
Indianapolis, IN 46204
Email:  pla3@pla.IN.gov
(317) 234-2060
(317) 233-4236 (fax)

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.

 *****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.

1. APPLICATION - Please complete and submit the application to the above address.  Original signature is required.  Please be specific when completing the job specification portion of the application.

2. FEE – Submit the one hundred dollar ($100) fee made payable to Professional Licensing Agency. Fees are non-refundable and non-transferable.

3. PHOTOGRAPH – Attach one (1) passport type quality photograph of your self taken within the last 8 weeks.

4. PROOF OF GRADUATION – You may submit proof of graduation by submitting one of the following documents:

                   (a) OFFICIAL TRANSCRIPT – An official transcript of grades from the medical/osteopathic school, confirming medical degree.  Include translation if not in English.

                   (b) DEGREE – A notarized copy of your medical / osteopathic degree. Include  official translation if not in English. (SEE NOTARIZED COPY NOTE ABOVE)

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 and expiration date will be acceptable.

 

NOTE: A Non-Renewable, Limited Scope, Temporary Permit may be issued to an Applicant only once. THIS PERMIT IS VALID FOR A NON-RENEWABLE PERIOD OF NOT MORE THAN THIRTY (30) DAYS.