Indiana Administrative Code › Title 844 - MEDICAL LICENSING BOARD OF INDIANA › Article 2.2 - PHYSICIAN ASSISTANTS › Rule 2 - General Provisions › Section 2-1 - Applications

Current through July 10, 2024
Authority: IC
				  25-22.5-2-7; IC
				  25-27.5-3-5
Affected: IC
				  25-22.5-1-2; IC 25-27.5
Sec. 1.
(a) The
				application for licensure of a physician assistant must be made upon forms
				supplied by the committee.
(b) Each
				application for licensure as a physician assistant or for a temporary permit
				shall include all of the following information:
(1) Complete names, address, and telephone
				number of the physician assistant.
(2) Satisfactory evidence of the following:
(A) Completion of an approved educational
				program.
(B) Passage of the
				Physician Assistant National Certifying Examination administered by the
				NCCPA.
(C) A current NCCPA
				certificate.
(D) Official
				transcripts or a notarized copy of transcripts or a notarized copy of CE
				certificates indicating completion of thirty (30) contact hours of
				pharmacology.
(E) A letter signed
				by an employer, past or present, listing the time frame of full-time employment
				resulting in one thousand eight hundred (1,800) hours in a twelve (12) month
				period.
(F) Must possess a current
				Indiana physician assistant license or have submitted an application in
				conjunction with prescribing authority application.
(3) All names used by the physician
				assistant, explaining the reason for such name change or use.
(4) The date and place of birth of the
				physician assistant and age at the time of application.
(5) Citizenship and visa status, if
				applicable.
(6) Whether the
				physician assistant has been licensed, certified, or registered in any other
				jurisdiction and, if so, the dates thereof.
(7) Whether the physician assistant has had
				disciplinary action taken against the license, certificate, or registration by
				the licensing or regulatory agency of any other state or jurisdiction and the
				details and dates thereof.
(8) A
				complete listing of all places of employment, including:
(A) the name and address of the
				employers;
(B) the dates of each
				employment; and
(C) employment
				responsibilities held or performed;
that the applicant has had since becoming a physician
				  assistant in any state or jurisdiction.
(9) Whether the physician assistant is, or
				has been, addicted to, or is chemically dependent upon, any narcotic drugs,
				alcohol, or other drugs and, if so, the details thereof.
(10) Whether the applicant has been denied
				licensure, certification, approval, or registration as a physician assistant by
				any other state or jurisdiction and, if so, the details thereof, including the
				following:
(A) The name and location of the
				state or jurisdiction denying:
(i)
				licensure;
(ii)
				certification;
(iii) approval;
				or
(iv)
				registration.
(B) The
				date of the denial.
(C) The reasons
				relating to the denial.
(11) Whether the physician assistant has been
				convicted of, or pleaded guilty to, any violation of federal, state, or local
				law relating the:
(A) use;
(B) manufacturing;
(C) distributing;
(D) sale;
(E) dispensing; or
(F) possession;
of controlled substances or of drug addiction and, if so, all
				  of the details relating thereto.
(12) Whether the physician assistant has been
				convicted of, or pleaded guilty to, any federal or state criminal offense,
				felony, or misdemeanor, except for traffic violations that resulted only in
				fines and, if so, all of the details thereto.
(13) Whether the physician assistant was
				denied privileges in any hospital or health care facility, or had such
				privileges revoked, suspended, or subjected to any restriction, probation, or
				other type of discipline or limitation, and, if so, all of the details relating
				thereto, including the:
(A) name and address
				of the hospital or health care facility;
(B) date of the action; and
(C) reasons therefor.
(14) Whether the physician assistant has ever
				been admonished, censured, reprimanded, or requested to withdraw, resign, or
				retire from any hospital or health care facility in which the physician
				assistant was employed, worked, or held privileges.
(15) Whether the physician assistant has had
				any malpractice judgments entered against him or her or settled any malpractice
				action or cause of action and, if so, a complete, detailed description of the
				facts and circumstances relating thereto.
(16) One (1) passport-type photo taken of the
				applicant within the last eight (8) weeks.