Free 53314.FH11 - Indiana

APPLICATION FOR PRESCRIPTIVE AUTHORITY FOR A PHYSICIAN ASSISTANT
State Form 53314 (R / 1-08) Approved by State Board of Accounts, 2008

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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

INSTRUCTIONS:

Please type or print clearly in ink.

FOR OFFICE USE ONLY
Date prescriptive authority issued (month, day, year)

* 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.

PHYSICIAN ASSISTANT INFORMATION
Name (last, first, middle) Mailing address (number and street or rural route, city, state, and ZIP code) Social Security number * E-mail address Date of birth (month, day, year) Telephone number Physician assistant license number Are you also applying for a Controlled Substances Registration application?

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Yes

No

SUPERVISING PHYSICIAN INFORMATION
Name of supervising physician Location of practice (number and street or rural route, city, state, and ZIP code) Date began employment with current supervising physician (month, day, year) License number

LIST PREVIOUS SUPERVISING PHYSICIANS FOR LAST TWO YEARS (attach additional sheet, if necessary) DATE BEGAN DATE ENDED LOCATION OF PRACTICE NAME LICENSE NUMBER EMPLOYMENT EMPLOYMENT

PHYSICIAN ASSISTANT DIPLOMA GRANTED BY
Full name of school (do not abbreviate) Date of graduation (month, day, year)

Please include proof of thirty (30) contact hours of Pharmacology with your application. NCCPA CERTIFICATE
NCCPA Certificate number Date granted (month, day, year) Date of expiration (month, day, year)

If your answer is "yes" to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event, including the location, date, and disposition. Falsification of any of the following is grounds for permanent revocation of the prescriptive authority 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 or country? 2. Have you ever surrendered or been denied a license, certificate, registration or permit to practice as a health care professional regulated in any state or country? 3. Are there charges pending against you regarding a violation of any Federal, State or local law relating to the use, manufacturing, distribution, or dispensing of controlled substances, alcohol, or other drugs? 4. Are you now being, or have you ever been, treated for drug or alcohol abuse or addiction? 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, alcohol, or other drugs? b. Any offense, misdemeanor, or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 6. Have you ever been the subject of an investigation by an authority regulating your profession? Page 1 of 2 Yes Yes Yes Yes Yes Yes Yes No No No No No No No

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 Board certification License number Social security number *

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Specialty

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, AND COMPLY WITH IC 25-27.5. 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 applicant 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 applicant Date (month, day, year)

Please include with this application, on a separate sheet of paper, a letter from your current of former supervising physician attesting to the fact that you have been continuously employed full time as a physician assistant for not less than one (1) year after graduating from a physician assistant program approved by the Committee. To be considered to have been continuously employed as a physician assistant for one (1) year for purposes of this subsection, a person must have worked as a physician assistant more than one thousand eight hundred (1,800) hours during the year. The letter must be on letterhead with the name and license number of the supervising physician and must be signed by the supervising physician. Page 2 of 2