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 on forms supplied by the committee.

(b) An application for licensure as a physician assistant or a temporary permit must include all the following information:

1. (1) Complete name, address, and telephone number of the physician assistant.

2. (2) Satisfactory evidence of the following:

   1. (A) Completion of required pharmacology training from a physician assistant program accredited by the Accreditation Review Commission on Education for the Physician Assistant.
   2. (B) Passage of the Physician Assistant National Certifying Examination administered by the NCCPA.
   3. (C) A current NCCPA certificate.
   4. (D) A current Indiana physician assistant license or a submitted application in conjunction with prescribing authority application.
3. (3) The names used by the physician assistant, explaining the reason for a name change or use.
4. (4) The date and place of birth of the physician assistant and their age at the time of application.
5. (5) Citizenship and visa status, if applicable.
6. (6) Whether the physician assistant has been licensed, certified, or registered in any other jurisdiction and, if so, the dates they were licensed, certified, or registered.
7. (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 of the disciplinary action.

8. (8) A complete listing of each place of employment, including:

   1. (A) the name and address of the employers;
   2. (B) the dates of each employment; and
   3. (C) employment responsibilities held or performed;
9. that the applicant has had since becoming a physician assistant in any state or jurisdiction.
10. (9) Whether the physician assistant is or has been addicted to, or chemically dependent on narcotic drugs, alcohol, or other drugs and, if so, the details of the addiction.

11. (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 of the denial, including the following:

    1. (A) The name and location of the state or jurisdiction denying:

       1. (i) licensure;
       2. (ii) certification;
       3. (iii) approval; or
       4. (iv) registration.
    2. (B) The date of the denial.
    3. (C) The reasons relating to the denial.

12. (11) Whether the physician assistant has been convicted of, or pleaded guilty to, any violation of federal, state, or local law relating to the:

    1. (A) use;
    2. (B) manufacturing;
    3. (C) distributing;
    4. (D) sale;
    5. (E) dispensing; or
    6. (F) possession;
13. of controlled substances or drug addiction and, if so, the details relating thereto.
14. (12) Whether the physician assistant has been convicted of, or pleaded guilty to, a federal or state criminal offense, felony, or misdemeanor, except for traffic violations that resulted only in fines and, if so, the details thereto.

15. (13) Whether the physician assistant was denied privileges in any hospital or health care facility, or had those privileges revoked, suspended, or subjected to any restriction, probation, or other type of discipline or limitation, and, if so, the details relating to the denial, including the:

    1. (A) name and address of the hospital or health care facility;
    2. (B) date of the action; and
    3. (C) reasons for the denial.
16. (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 where the physician assistant was employed, worked, or held privileges.
17. (15) Whether the physician assistant has had any malpractice judgments entered against them or settled any malpractice action or cause of action and, if so, a complete, detailed description of the facts and circumstances relating to the judgments or actions.

(c) The information in an application shall be submitted under oath or affirmation, subject to the penalties of perjury.

(d) An applicant for licensure as a physician assistant shall submit an executed authorization and release form provided by the committee that:

1. (1) authorizes the committee or any of its authorized representatives to inspect, receive, and review the documents, records, or other information pertaining to the applicant;

2. (2) authorizes and directs any:

   1. (A) person;
   2. (B) corporation;
   3. (C) partnership;
   4. (D) association;
   5. (E) organization;
   6. (F) institute;
   7. (G) forum; or
   8. (H) officer thereof;
3. to give the committee the relevant documents, records, or other information pertaining to the applicant; and

4. (3) releases the committee, or any of its authorized representatives, and any:

   1. (A) person;
   2. (B) corporation;
   3. (C) partnership;
   4. (D) association;
   5. (E) organization;
   6. (F) institute;
   7. (G) forum; or
   8. (H) officer thereof;
5. from all liability regarding inspecting, reviewing, receiving, or supplying that information.

(e) Application forms submitted to the committee must be complete. Supporting documents required by the application must be submitted with the application.

(f) Applicants for a temporary permit to practice as a physician assistant while waiting to take the examination or awaiting results of the examination shall submit the requirements of subsection (b), except for subsection (b)(2)(B) and (b)(2)(C), to apply for a temporary permit.

(g) A temporary permit becomes invalid if the temporary permit holder fails to sit or register for the next available examination.

(h) Before beginning practice as a physician assistant, the physician assistant shall submit a collaboration agreement to the committee, which must be approved by the board. The collaboration agreement must:

1. (1) be submitted on the employer's letterhead;
2. (2) be written specifically for the applicant; and
3. (3) contain the original signature of both the applicant and collaborating physician, and the date signed.

(Medical Licensing Board of Indiana; 844 IAC 2.2-2-1; filed May 26, 2000, 8:52 a.m.: 23 IR 2498; errata filed Sep 21, 2000, 3:21 p.m.: 24 IR 382; filed Jan 2, 2003, 10:38 a.m.: 26 IR 1558; readopted filed Dec 1, 2009, 9:13 a.m.: 20091223-IR-844090779RFA; filed Apr 6, 2010, 2:52 p.m.: 20100505-IR-844090164FRA; readopted filed Nov 22, 2016, 12:11 p.m.: 20161221-IR-844160317RFA; readopted filed Nov 22, 2022, 12:22 p.m.: 20221221-IR-844220255RFA; readopted filed Feb 27, 2024, 10:19 a.m.: 20240327-IR-844230772RFA; filed Jun 20, 2025, 3:41 p.m.: 20250716-IR-844240435FRA)