Free 29495.FH11 - Indiana

APPLICATION FOR A LICENSE TO PRACTICE MEDICINE / OSTEOPATHIC MEDICINE IN INDIANA
State Form 29495 (R14 / 5-08) Approved by State Board of Accounts, 2008

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MEDICAL LICENSING BOARD OF INDIANA 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. ** This information is being requested for workforce statistical purposes only; disclosure is voluntary.

FOR OFFICE USE ONLY
Application fee Receipt number License number Permit fee Receipt number Permit issuance date (month, day, year) Date fee paid (month, day, year) Application number License issuance date (month, day, year) Date fee paid (month, day, year) Permit number

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

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle) Address of practice (number and street or rural route) City, state, and ZIP code T elephone number (daytime) Date of birth (month, day, year) Ethnicity ** Race ** Gender ** Check one: MD DO Social Security number *

(

)

Male

Female

Mailing address (number and street, city, state, and ZIP code) [if different from above] E-mail address National Provider Identifier number

TEMPORARY PERMIT INFORMATION Do you desire a temporary permit? Yes No

DOCTOR OF MEDICINE / OSTEOPATHIC DEGREE GRANTED BY A foreign medical school must meet LCME standards at the time of graduation.
Name of school Specialties Location Date of graduation (month, day, year)

Board certification (list ABMS certification)

EXAMINATION Check appropriate box(es) indicating which examination or combination of examinations you have taken. (Please review instruction sheet for address and telephone numbers on how scores may be obtained.) FLEX EXAMINATION Component I Component II Other STATE BOARD EXAMINATION Examination taken in which state? LMCC EXAMINATION

NATIONAL BOARD OF MEDICAL EXAMINERS Part I Part II Part III

USMLE EXAMINATION Step I Step II Step III

NATIONAL BOARD OF OSTEOPATHIC MEDICAL EXAMINERS Part I Part II Part III

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NAME OF SCHOOL

PRE-MEDICAL / OSTEOPATHIC EDUCATION LOCATION

DATES ATTENDED (month, day, year)

MEDICAL / OSTEOPATHIC EDUCATION A foreign medical school must meet LCME standards at the time of graduation. NAME OF SCHOOL LOCATION DATES ATTENDED (month, day, year)

POSTGRADUATE MEDICAL / OSTEOPATHIC EDUCATION AND TRAINING IN THE UNITED STATES OR CANADA (Include ALL internships, residencies and / or fellowships) All programs must have been ACGME accredited at the time of enrollment. NAME OF PROGRAM LOCATION FROM (month, year) TO (month, year) ACGME / AOA / RC ACCREDITED? Yes Yes Yes Yes LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM MEDICAL OR OSTEOPATHIC SCHOOL DATE (month, day, year) GENERAL LOCATION No No No No

NAME AND ADDRESS OF EMPLOYER

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM MEDICAL OR OSTEOPATHIC SCHOOL DATE (month, day, year) RESPONSIBILITIES

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 CURRENT STATUS

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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 and disposition. If malpractice, provide name(s) of plaintiff(s), case information, detailed description of case / events and settlement amount, including 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? 2. Have you ever been denied a license, certificate, registration or permit to practice medicine, osteopathic medicine or any regulated health occupation in any state (including Indiana) or country, or surrendered your license? 3. Are you now being, or have you ever been treated for drug or alcohol abuse or addiction? 4. Have you ever been the subject of an investigation by a regulatory agency concerning your license? 5. Have you ever been convicted of, plead guilty or nolo contendere to, or are charges pending: 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? 9. Have you ever surrendered your DEA registration at any time or had any limitations placed on your DEA registration? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

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 authorized, 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 medical licensure. 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 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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