Free 09237.FH11 - Indiana

APPLICATION FOR LICENSURE AS A PHYSICIAN ASSISTANT
State Form 9237 (R6 / 1-08) Approved by State Board of Accounts, 2008

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INSTRUCTIONS:

Please print clearly in ink.

PHYSICIAN ASSISTANT 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 being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY

FEE RECEIVED DATE RECEIVED (month, day, year) RECEIPT NUMBER LICENSE NUMBER ISSUED ISSUANCE DATE (month, day, year) DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name (last, first, middle) Address (number and street or rural route) City, state, and ZIP code Social Security number * Telephone number (daytime) Date of birth (month, day, year) Email address Place of birth

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

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TEMPORARY PERMIT
Do you desire a temporary permit?

PRESCRIPTIVE AUTHORITY
Are you applying for prescriptive authority?

Yes

No BASIS FOR LICENSURE

Yes

No

Endorsement
Name of school

Examination

Date taking NCCPA examination:
Date of graduation (month, day, year)

PHYSICIAN ASSISTANT DIPLOMA GRANTED BY

Address of school (number and street or rural route, city, state and ZIP code)

NCCPA CERTIFICATE
Certificate number Date granted (month, day, year) Date of expiration (month, day, year)

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

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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, disposition and all court documents, if applicable. If malpractice, provide name(s) of plaintiff(s), case information, detailed description of case / events and settlement amounts. 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? 2. Have you ever been denied a license, certificate, registration or permit to practice as a physician assistant or 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 the subject of an investigation by an authority regulating your profession? 5. Have you ever been arrested, convicted, 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 substances or drug addiction ? B. Any offense, misdemeanor or felony in any state ? (Except for minor violations of traffic laws resulting in fines.) 6. 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? 7. 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? 8. Have you ever had a malpractice judgment against you or settled any malpractice action? LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM PHYSICIAN ASSISTANT SCHOOL RESPONSIBILITIES NAME AND ADDRESS OF EMPLOYER Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes No No No No

DATE

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)

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 its authorized representatives in connection with processing my application for licensure as a Physician Assistant. 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 Physician Assistant Committee 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 the same.
Signature of applicant Date signed (month, day, year)

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SUPERVISING PHYSICIAN'S STATEMENT
Name of Supervising Physician (last, first, middle) Residence address (number and street or rural route, city, state, and ZIP code) Address of practice (number and street or rural route, city, state, and ZIP code) Residence telephone number Office telephone number E-mail address License number Social security number *

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Specialty

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Board certification

SUPERVISORY AGREEMENT FOR THE PHYSICIAN ASSISTANT INSTRUCTIONS: ON AN ATTACHED SHEET, give a detailed description of the exact privileges and tasks the physician assistant shall be performing under the physician's supervision. In addition, please give a detailed description of the process maintained for evaluation of the physician assistant's performance. THIS SUPERVISORY AGREEMENT MUST BE ON COMPANY LETTERHEAD (including address, telephone number, and fax number), BE PERSON SPECIFIC, AND BE SIGNED BY BOTH THE PHYSICIAN ASSISTANT AND THE SUPERVISING PHYSICIAN. LIMIT ON PHYSICIAN ASSISTANT SUPERVISION As a supervising physician, I understand that I may supervise no more than two (2) physician assistants. Please indicate below the name and certificate number of the physician assistant you are currently supervising, if any.
Name of physician assistant License number

CERTIFICATION OF SUPERVISION

Please indicate by signing your name below that the physician assistant named in this application will be under your continuous supervision in accordance with IC 25-27.5-6, IC 25-27.5-2-14 and 844 IAC 2.2, and that you shall review all records of patient encounters maintained by the physician assistant within 24 hours after the physician assistant has seen a patient and at all times retain professional and legal responsibility for the care rendered by the physician assistant.
Signature of supervising physician Date (month, day, year)

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 supervising physician Date (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 its authorized representatives in connection with processing my application for supervising physician. 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 Physician Assistant Committee from any and all liability in connection with such disclosures. 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 supervising physician Date (month, day, year)

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