Free 42907.FH11 - Indiana

APPLICATION FOR CHANGE OR ADDITION OF SUPERVISING PHYSICIAN FOR PHYSICIAN ASSISTANTS
State Form 42907 (R4 / 1-08) Approved by State Board of Accounts, 2008

Reset Form

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 I. C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY
Date received (month, day, year) License number issued Amount of fee received

Receipt number

Date issuance (month, day, year)

DO NOT WRITE ABOVE THIS LINE
TO BE COMPLETED BY THE PHYSICIAN ASSISTANT (please print clearly in ink)
Name (last, first, middle) Address (number and street or rural route) City Social Security number * Date of birth (month, day, year) State E-mail address ZIP code Telephone number (daytime) Physician Assistant license number

(

)

Are you applying for a change of supervising physician?

Name of supervising physician prior to completion of this application

Yes
Name of new supervising physician

No
Date of discontinuation of supervision of physician (month, day, year)

Office address of new supervising physician (number and street, city, state, and ZIP code) Specific reason for discontinuation of supervision:

Do you currently have prescriptive authority?

Are you applying for prescriptive authority?

Yes Yes

No No (if yes, indicate new address )

Yes

No

Are you applying to change your controlled substance address? Name(s) of additional supervising physician (indicate all)

New address (number and street, city, state, and ZIP code)

Office address of additional supervising physician (number and street, city, state, and ZIP code)

I hereby swear or affirm under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of Physician Assistant 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 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 Committee from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of Physician Assistant Date (month, day, year)

Page 1 of 2

SUPERVISING PHYSICIANS 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 Board certification License number Social Security number *

(

)

(

)

Specialty

SUPERVISORY AGREEMENT FOR THE PHYSICIAN ASSISTANT INSTRUCTIONS: ON AN ATTACHED SHEET, give a description of the exact privileges and tasks the physician assistant shall be performing under the physicians supervision. In addition, please give a detailed description of the process maintained for evaluation of the physician assistants performance. THIS SUPERVISORY AGREEMENT MUST BE ON COMPANY LETTERHEAD, INCLUDING FACILITY ADDRESS AND TELEPHONE NUMBER, BE SPECIFIC TO THE APPLICANT, AND BE SIGNED BY BOTH THE PHYSICIAN AND THE PHYSICIAN ASSISTANT. 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 license 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 time retain professional and legal responsibility for the care rendered by the physician assistant.
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)

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 Committee from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force 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)

Page 2 of 2