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Application and Instructions for Licensure as a Physician Assistant

Physician Assistant Licensure Application

You must complete, date and sign the application for licensure.  All information must be completed on the application or have N/A for not applicable. An email address is mandatory.  All correspondence regarding the status of your application will be sent via email, as well as all future license renewal information.

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.  Once you obtain employment you must then complete a change/addition application, submit it with payment and a collaborative agreement.  You will not be able to practice until we have a collaborative agreement on file.  Initial licenses issued 90 days before the renewal date of all licensees do not expire until the next renewal cycle. If you have any questions concerning this please feel free to contact the Committee staff.

Documents Required for Licensure

Photograph - Submit one (1) passport quality photo taken within the past eight (8) weeks.

Application Fee - Please submit an application fee in the amount of $100.00  payable to Professional Licensing Agency.  All fees are non-refundable and non-transferable.

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.

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 include the amount paid in your behalf.  An affidavit is not needed if you responded to Question #12 regarding employment history. 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; however they may be included with your statement.

Criminal Background Checks - Any physician assistant seeking initial licensure are required to submit to fingerprinting and a national criminal background check by the Indiana State Police.  The individual applicant will be responsible for the cost of the background check.  The backgrounds must be done by the state approved vendor and any checks done outside the chain of command will not be accepted.  Information on how to be fingerprinted and a list of frequently asked questions, go to criminal background check information.

Official Transcript - Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been confirmed.

Score Report - 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)
Website:  http://www.nccpa.net/

NCCPA Certificate - Submit a notarized copy of your current NCCPA certificate.

Verification of State Licensure(s) - 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 physician assistant license/certification etc., this also pertains to any professional health license such as an EMT, nurse, pharmacist, etc. You will need to print off the verification form and contact the appropriate entities/states regarding their process.  They may charge a fee for this service.  They will need to complete the verification and mail it directly to our office.  Many states use their own computer generated document, in lieu of our form, which is acceptable. We do accept official web verifications; the verification must come directly from the State in which you were licensed.

Collaborative Agreements - Click here for information on collaborative agreements. 


Controlled Substances - Click here for information on applying for a controlled substance registration. 

Chart Review & Supervision
- The review of patient encounters will require review within 10 days for the following:

• 1st year- 10% 
• Subsequent years- percentage collaborating physician determines to be reasonable as stated in the collaborative agreement

IC 25-27.5-6-1

Temporary Permit

Your application file must be complete and pending Committee review before a temporary permit may be issued.  If you wish to practice while waiting for your application file to be reviewed you must apply for and obtain a temporary permit. 

According to IC 25-27.5-4-4
(a) The committee may grant a temporary license to an applicant who meets all qualifications for licensure (including the passage of the examination) and is awaiting the next scheduled meeting of the committee.
(b) A temporary license is valid until the committee makes a final decision on the applicant's request for a license.            

If applying for a temporary permit you must also submit along with the application fee, a payment of $50.00 made payable to Professional Licensing Agency.  All fees are non refundable and non transferable.