Free 50711.FH11 - Indiana

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APPLICATION FOR CERTIFICATION AS AN ACUPUNCTURE DETOX SPECIALIST
State Form 50711 (R / 2-06) Approved by State Board of Accounts, 2006

INDIANA ACUPUNCTURE ADVISORY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2060 E-mail: [email protected] www.pla.IN.gov

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSE ISSUED (month, day, year) APPLICANT Attach two (2) passport type quality photographs of yourself taken within the last eight weeks.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle) Address (number and street or rural route) City, state, and ZIP code Telephone number (daytime) Email address Birthplace Social Security number *

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Date of birth (month, day, year)

HIGH SCHOOL DIPLOMA / GED GRANTED BY
Name of school Location Date of graduation (month, year)

ACUPUNCTURE TRAINING FOR DETOXIFICATION NAME OF PROGRAM LOCATION NUMBER OF HOURS DATE CERTIFIED (month, day, year)

NAME OF SCHOOL

OTHER EDUCATION AND TRAINING IN THE UNITED STATES LOCATION FROM (month, year)

TO (month, year)

LIST ALL PLACES YOU HAVE LIVED SINCE YOUR MOST RECENT DEGREE GENERAL LOCATION

DATE (month, day, year)

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LIST ALL PLACES YOU HAVE WORKED SINCE YOUR MOST RECENT DEGREE NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES

DATE (month, day, year)

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE ANY REGULATED HEALTH OCCUPATION STATE TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT NUMBER DATE ISSUED (month, day, year) CURRENT STATUS

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If it is a malpractice settlement or judgment against you, please provide name(s) of plaintiff(s), case summary, settlement amount and include court documents, if applicable. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following, is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held in any state? 2. Has you ever been denied a license, certificate, registration or permit to practice any regulated health occupation in any state (including Indiana) or country? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been arrested, convicted of, pled guilty or nolo contendere to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substance or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor traffic laws resulting in fines.) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? 8. Have you ever been the subject of an investigation by a regulatory agency concerning a license? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of their authorized representatives in connection with processing my application for acupuncture detoxification specialist. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Medical Licensing Board from any and all liability in connection with such disclosure. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE SUPERVISOR
SUPERVISING PHYSICIAN / ACUPUNCTURIST / PROFESSIONAL ACUPUNCTURIST
Name of supervisor (last, first, middle) License number Residence address (number and street, city, state, and ZIP code) Office address (number and street, city, state, and ZIP code) Residence telephone number Office telephone number Social Security number * Date license expires (month, year)

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Date of birth (month, day, year) Email address

Place of birth

MEDICAL, PROFESSIONAL / ACUPUNCTURE DEGREE
Name of school Location Date of graduation (month, day, year)

INSTRUCTIONS: Give a description of your practice, areas of specialization, and / or board certification

JOB DESCRIPTION FOR THE ADS INSTRUCTIONS: ON AN ATTACHED SHEET, give a description of the exact privileges and tasks the ADS shall be performing under your supervision. In addition, please give a detailed description of the process maintained for evaluation of the ADS. Please provide on letterhead and include address and telephone number. LIMIT ON ADS SUPERVISION As a supervising physician or professional acupuncturist or acupuncturist, I understand that I may NOT supervise any more than twenty (20) Acupuncture Detox Specialists at a time. Please list the names and certificate numbers of the ADS you are currently supervising.

CERTIFICATION OF SUPERVISION Please indicate by signing your name below that the Acupuncture Detox Specialists (ADS) named in this application will be under your continuous supervision in accordance with IC 25-2.5 and 844 IAC 13, and that you shall review all records of patient encounters performed by the ADS at least one time per month after the encounter and at all times retain professional and legal responsibility for the care rendered by the ADS.
Signature of supervisor Date signed (month, day, year)

AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of supervisor Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of their authorized representatives in connection with processing this application for acupuncture detoxification specialist certification. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and hereby specifically release the Agency, and the Medical Licensing Board from any and all liability in connection with such disclosure. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of supervisor Date signed (month, day, year)

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