Change and Addition of Supervising Physician Application
The Physician Assistant and the Supervising Physician must complete, date and sign the application and return it to the Professional Licensing Agency along with the items listed below:
Application Fee - The fee for the change and addition application is $50.00. Please make all checks payable to the Professional Licensing Agency.
Supervisory Agreement - The Supervising Physician shall submit a description of the exact privileges and tasks the physician assistant shall be performing under the physician’s supervision. The supervising agreement shall be specific to the physician assistant being hired “i.e. John Brown, PA will be responsible for…” In addition give a detailed description of the process maintained for evaluation of the physician assistant’s performance. Also include a description of procedures for dealing with emergencies. The supervising agreement must be on letterhead and signed by both the physician and physician assistant.
If the physician assistant has been granted prescriptive authority or is applying for prescriptive authority in conjunction with this change/addition application, the supervising agreement must also include a list of classifications of medications the physician assistant is delegated to prescribe. Description of protocols used in the practice. Protocols to be used for physician assistant prescribing may include clinical practice guidelines, reference texts, or other sources.
In accordance with IC 25-27.5-6-2, a physician may have supervising agreements with more than two (2) physician assistants, however may not supervise more than two (2) physician assistants at any given time. The application is currently in revision process to reflect this.