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Indiana Professional Licensing Agency

PLA > Professions > Medical Licensing Board of Indiana > Expired Non-renewable instructions for MD Expired Non-renewable instructions for MD

Licensure Application

Controlled Substance Registration

State Verification Form

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION.  If after reading the instructions you have questions please contact our office.

 

CONTACT INFORMATION
Indiana Professional Licensing Agency
Physician Assistant Committee
402 West Washington Street, Room W072
Indianapolis, IN 46204
E-mail:  pla3@pla.in.gov
(317) 234-2060
(317) 233-4236(fax)

 

PROCESSING TIME

Processing time depends on the Applicant.  The applicant is responsible for the submission of all documents.  The sooner the documents are requested and received the quicker the license can be issued.  If you have a positive response the license/temporary cannot be issued until it has been reviewed by the Board.  The Board meets on a monthly basis.

FAIR INFORMATION PRACTICE ACT

In compliance with IC 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 circumstances where their release is required by law, in which case you will be notified.  Your social security number is being requested by this state agency in accordance with IC 4-1-8-1.  Disclosure is mandatory, and this record cannot be processed without it.

A NOTE ABOUT LICENSURE & TEMPORARY PERMITS

Licensure is entirely at the discretion of the Medical Licensing Board of Indiana.  Licensure in another state does not in any manner assure or guarantee licensure in Indiana.  The completion of an application does not guarantee licensure in Indiana.  Holding a previous license in Indiana does not in any manner assure or guarantee re-licensure in Indiana.

NOTARIZED COPY INFORMATION

When submitting a notarized copy of an original document, the notary MUST make a statement to the fact that the notary has seen the original document.  If this is not done the document will NOT be accepted.

STATUTES AND RULES

You may view the statute and rules on our website by clicking here

                   DOCUMENTS REQUIRED FOR LICENSURE

(To reinforce the notarized copy information listed on the top of page two:  When submitting a notarized copy of an original document, the notary MUST make a statement to the fact that the notary has seen the original document.  If this is not done the document will NOT be accepted. )

You will need to complete an MD/DO Application for licensure.  Please type or legible print when completing the application.  All information requested on the application must be completed.  The application must have an original signature and date. 

Please indicate at the top of your application “Previous License Expired/Reapplying” and if you know your previous Indiana license number please document it also.

  • PHOTOGRAPH

You must submit one (1) passport quality photo taken with in the past three (3) months.

  • FEE

You must submit an application fee in the amount of $250.00; payable to Professional Licensing Agency.  All fees are non-refundable and non-transferable.

  • POSITIVE RESPONSES

If you have answered any of the questions on the application “yes” you must submit a NOTARIZED AFFIDAVIT detailing the occurrence/situation, the outcome, date of occurrence, if it is a malpractice payment the amount paid in your behalf.  If applicable please submit copies of all court documents and/or arrest records.  Letters from attorneys or insurance companies are not accepted in lieu of your statement. 

  • TEMPORARY PERMIT

A ninety (90) day temporary permit may be issued to an applicant who holds and shows proof of holding a valid license to practice medicine in the United States, its possessions or Canada.

If you are also requesting a ninety (90) day temporary permit; along with the first four (4) items listed above you must also submit:

      --Proof of Current Licensure.  You must submit a notarized copy of a license with a         current expiration date (pocket card/billfold license).

--An additional temporary permit fee of $100.00; payable to Professional Licensing        Agency.  All fees are non-refundable and non-transferable.

The permit expires ninety (90) days from the date of issuance or when final action is taken on the application for licensure.

You must request a “License Verification or Letter of Good Standing” from each State/Country in which you currently are or have ever been licensed, certified, or registered in any regulated health profession or occupation.  This includes all licenses etc., that are active, expired, inactive, retired, delinquent etc.  In addition to any Medical license/permit etc., this also pertains to any professional health license such as an EMT, Nursing, Pharmacists, etc.  You will need to print off the verification form; contact the appropriate entities/states to see if they charge a fee for completing this form and send the form directly to them.  They will in turn complete the verification and mail it directly to our office.  We do not accept web verifications; the verification must come directly from the state in which you were licensed.

  • WORK HISTORY

You must submit a letter of work history that covers from the time your original license in Indiana expired to the present date. 

Please note that if you have not practiced for three (3) or more you will need to demonstrate competency.

  • NPDB/HIPDB REPORT

Please contact the National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank and request a report.  The report will be sent directly to you. 

DO NOT OPEN the report, but forward the unopened envelope to our office.  If you do open the envelope please send the ENTIRE CONTENT and the envelope to our office.  (There are not two copies of the report in the envelope but two separate reports and we need both for licensure purposes.)  Please note that we must have the envelope too to show proof that it was sent from NPDB.

NPDP/HIPDB Contact Information
P. O. Box 10832
Chantilly, VA 20153-0832
Website:
http://www.npdb-hipdb.hrsa.gov/