Indiana Administrative Code › Title 844 - MEDICAL LICENSING BOARD OF INDIANA › Article 4 - MEDICAL DOCTORS; OSTEOPATHIC DOCTORS › Rule 4.5 - Licensure to Practice › Section 4.5-7 - Application for a license

Current through July 10, 2024
Authority: IC 25-22.5-2-7
Affected: IC 25-1-8-2
Sec. 7.
(a) A person
				seeking licensure to practice medicine or osteopathic medicine shall file an
				application on a form supplied by the board and submit the fees required by
				844 IAC 4-2-2. (b) The applicant
				for a license shall provide the following:
(1) Where the name on any document differs
				from the applicant's name, a notarized or certified copy of a marriage
				certificate or legal proof of name change must be submitted with the
				application.
(2) One (1) recent
				passport-type photograph of the applicant, taken within eight (8) weeks prior
				to filing of the application.
(3) A
				certified copy of the original medical school or osteopathic medical school
				diploma. The following are requirements in the event that such diploma has been
				lost or destroyed:
(A) The applicant shall
				submit, in lieu thereof, a statement under the signature and seal of the dean
				of the medical school or osteopathic medical school or college from which the
				applicant graduated, stating that the applicant has satisfactorily completed
				the prescribed course of study, the actual degree conferred, and the date of
				graduation.
(B) The applicant shall
				submit an affidavit fully and clearly stating the circumstances under which his
				or her diploma was lost or destroyed.
(C) In exceptional circumstances, the board
				may accept, in lieu of a diploma or certified copy thereof, other types of
				evidence, which establish that the applicant received a medical school or
				osteopathic medical school or college diploma and completed all academic
				requirements relating thereto.
(4) If the applicant is the graduate of a
				school of medicine or osteopathic medicine in the United States, its
				possessions, or Canada, an original transcript of the applicant's medical
				education, including the degree conferred and the date the degree was conferred
				must be submitted. If the original transcript is in a language other than
				English, the applicant must include a certified translation of the
				transcript.
(5) If the applicant is
				a graduate of a school of medicine or osteopathic medicine outside the United
				States, its possessions, or Canada, the applicant must submit an original
				transcript of the applicant's medical education, including the degree conferred
				and the date the degree was conferred. If the original transcript is in a
				language other than English, the applicant must include a certified translation
				of the transcript. If an original transcript is not available, the applicant
				must submit the following:
(A) A notarized or
				certified copy of the original medical school or osteopathic medical school
				transcript, which must include the degree conferred and the date the degree was
				conferred.
(B) An affidavit fully
				and clearly stating the reasons that an original transcript is not
				available.
(6) If the
				applicant has been convicted of a criminal offense (excluding minor traffic
				violations), the applicant shall submit a notarized statement detailing all
				criminal offenses (excluding minor traffic violations) for which the applicant
				has been convicted. This notarized statement must include the following:
(A) The offense of which the applicant was
				convicted.
(B) The court in which
				the applicant was convicted.
(C)
				The cause number under which the applicant was convicted.
(D) The penalty imposed by the
				court.
(7) If the
				applicant is a graduate of a school of medicine or osteopathic medicine outside
				the United States, its possessions, or Canada, the applicant must submit a
				notarized copy of a certificate issued to the applicant by the Educational
				Commission on Foreign Medical Graduates.
(8) All applicants who are now, or have been,
				licensed to practice any health profession in another state must submit
				verification of license status. This information must be sent by the state that
				issued the license directly to the Indiana board.
(9) The applicant shall submit a self-query
				form completed by the National Practitioner Data Bank and the Healthcare
				Integrity and Protection Data Bank.
(10) All information on the application shall
				be submitted under oath or affirmation, subject to the penalties for perjury.