If you have not secured employment, you do not need to complete or send in the Collaborating Physician page of the application, nor do you need to submit a collaborative agreement.  A license may be issued without both but you will not be able to work as a P.A..  Once you obtain employment you must then complete a change/addition application, submit it by mail with payment and a collaborative agreement.  You will not be able to practice until we have a collaborative agreement on file. 

1. Completed Application: Applications may be submitted online at MyLicense.IN.gov.
2. Application fee of $100.00: Pay by credit or debit card for applications submitted online.  All application fees are nonrefundable.
3. Criminal Background Check
4. Positive Response Documentation: If you answer "Yes" to any questions on the application, explain fully in a statement that includes all details. Include the violation, location, date, cause number, and disposition. Submit copies of court documents for each instance to support the statement. If malpractice, provide the name(s) of the plaintiff(s). Please upload at the time of application or log back into your account and use the License Update option.
5. Name Change Documentation: Documentation of any legal name change if your name differs from that on any of your documents. Documentation may include a copy of your marriage certificate or divorce decree.  Please upload at the time of application or log back into your account and use the License Update option.
6. Official Transcript: Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been confirmed. Please upload at the time of application or log back into your account and use the License Update option.
7. Copy of Diploma: An original copy of your diploma.  Please upload at the time of application or log back into your account and use the License Update option.
8. Score Report from the Examination administered by the NCCPA:  You must request that your official score report be sent directly to Professional Licensing Agency from the NCCPA.
   • National Commission on Certification
     of Physician Assistants
     12000 Findley Road, Suite 200
     Duluth, GA 30097
     (678) 417-8100
     (678) 417-8135 (fax)
     Email:  nccpa@nccpa.net
     Website:  http://www.nccpa.net/
9. Current NCCPA Certificate: A copy of your current NCCPA Certificate. Please upload at the time of application or log back into your account and use the License Update option.
10. Verification of Licensure: Verification of any registration/license/certification to practice any health-related profession or occupation in another state or territory.  Verifications must be submitted directly from the state of issuance.  The form is linked should you another state require the form to complete the request.
11. Collaborative Agreements - 
    1. Collaborative Agreement Checklist
    2. Collaborative Agreement Sample

The Fair Information Practice Act:  In compliance with Ind. Code 4-1-6, this agency is notifying you that you must provide the requested information, or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record. Your examination scores and grade transcripts are confidential except in circumstanes where their release is required by law, in which case you will be notified.

Mandatory Disclosure of U.S. Social Security Number: Your social security number is being requested by this state agency in accordance with Ind. Code 4-1-8-1 and 25-1-5- 11(a). Disclosure is mandatory, and this record cannot be processed without it. Failure to disclose your U.S. social security number will result in the denial of your application. Application fees are not refundable.

Abandon Applications:  If an applicant does not submit all requirements within one (1) year after the date on which the application is filed, the application for licensure is abandoned without any action of the Board. An application submitted after an abandoned application shall be treated as a new application.

All applications are subject to review and approval by the Physician Assistant Committee.

JOB DESCRIPTION OF PHYSICIAN ASSISTANT:

1. The supervising physician shall submit a description of the exact privileges and tasks the physician assistant shall be performing under the physician's supervision.
2. The job description must be personalized and specific to the individual physician assistant's skill level and responsibilities.
3. This job description must be on company letterhead and signed by the supervising physician and the physician assistant.
4. The company letterhead and/or job description must indicate the location of the primary cite of practice within the State of Indiana.
5. The supervising physician must sign pages 3 and 4 of the application for the application to be considered.

In accordance with IC 25-27.5-6-2, a physician may supervise not more than four (4) physician assistants at one time. Furthermore, according to IC 25-27.5-5-4 physician assistants may not prescribe certain things, please review. Again, be sure the job description is on company letterhead and signed by the supervising physician.

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CHART REVIEW & SUPERVISION

Chart review must be included in every collaborating agreement submitted to the Board.  If you are beginning employment with a new collaborating physician, the collaborating agreement must include that the collaborating physician will review for the 1st year 10% of the PA's files within 10 days.  This is for all PA's regardless of how long you have been practicing as a PA.

Example:

* Dr. Smith will review 10% of Jody Brown's files within 10 days.
* Subsequent years- the percentage of review will be determined by the collaborating physician and needs to be stated in the collaborating agreement.
IC 25-27.5-6-1

• Renew Online!
• Physician Assistant licenses expires on June 30th of even-numbered years.
• The physician assistant renewal fee is $50 if renewed on or before June 30th. If renewed after June 30th a late fee of $50 will be due in addition to your renewal fee.
• Physician assistants are required to maintain NCCPA certification in order to renew their license to an active status.
• If you have a Controlled Substance Registration (CSR), you must renew them also at the same time you renew your physician assistant license.  If you have more than one CSR you will need to renew each one.  If you have a different practice location than what is on your CSR, you will need to do one of the following:
  • Submit a email  stating that your current collaborating physician (give name and license number) has moved offices and you need to update the address on your  CSR or;
  • Submit a change/addition application, new collaborating agreement with new practice location listed and $50 application fee.  This application, agreement and fee must be mailed to our office as they are not currently online.

Renewal notices are sent approximately ninety (90) days prior to the expiration date. License holders with valid email addresses on file will be emailed the renewal notice. Those who do not have valid email addresses on file will be mailed the license renewal notice; this notice is mailed to the address of record with the board. The board has no way of knowing whether or not a notice reaches its destination; therefore, when a notice has been emailed to a valid email address or mailed , the duty of the board has been performed.

Inactive Status

You do not have to have a current NCCPA in order to renew on inactive status, but must renew your license and pay the renewal fee.

Controlled Substance Registration

If your primary license is currently in "Current/Not Practicing" you cannot renew your CSR.  Additionally, if you renew your primary license to the Inactive status, you cannot renew your Controlled Substance Registrations.  If you do attempt to renew the CSR without an Active primary, please keep in mind that all fees are nonrefundable and nontransferable.

Physician Assistant Application/Renewal	Fee	Temporary Permit	Penalty	Total
Initial Application (with Temporary Permit)	$100	$50	NA	$150
Change of Supervising Physician	$50	NA	NA	$50
Addition of Supervising Physician	$50	NA	NA	$50
Renewal - due 6/30 of even-numbered years	$50	NA	NA	$50
Controlled Substance Registration	$60	NA	NA	$60
Inactive Status	$25	NA	NA	$25