Application Instructions

• Anesthesiologist Assistant Licensure via Application
  1. Apply Online - Apply online
  2. Application Fee - $100.00 payable via credit or debit card.  Additional online processing fees apply.
  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.
  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.
  6. Official Transcript - An original official medical school transcript. The transcript must show the degree conferred and date the degree was conferred. A transcript is required from each institution you have attended. If the original transcript is in a language other than English, it must be accompanied by a certified translation.
  7. A current NCCAA certification is required for application. Verifications may be obtained through National Commission of Certification of Anesthesiologist Assistant's website: www.nccaa.org. Please upload at the time of application. Your NCCAA certification is not a license verification.
  8. Verification of other state licenses - an applicant who currently holds, or has previously held, a license, certification, or registration issued by another state to practice any health profession must request verification of license status from the state that issued that license, certification, or registration. The verification must be sent directly to the board from the agency that issued the license,  certification, or registration. Official electronic verification will also be accepted.
  9. Practice Protocol Agreement - Supervising physicians (or primary supervising physician of a physician group practice) must submit a practice protocol agreement that details the exact privileges and tasks the anesthesiologist assistant shall be performing under the physician's supervision. In addition, please give a detailed description of the process maintained for evaluation of the anesthesiologist assistant's performance. If you plan to attach a copy of the evaluation form to the agreement, you must specify in the agreement that you are doing so. This practice protocol agreement must be completely typed, on company letterhead, be person specific, and must include the anesthesiologist assistant's and supervising physician's name, (or primary supervising physician of a physician group practice),license numbers, the practice address, and be signed and dated by both the anesthesiologist assistant and the supervising physician, (or primary supervising physician of a physician group practice). If there are additional supervisors, their names and license numbers should be included as an addendum.
  10. Supervising Anesthesiologist Statement - State Form 57723

  • AA Practice Protocol Checklist
  • AA Practice Protocol Agreement Sample
• Anesthesiologist Assistant Licensure via Reciprocity
  1. Completed Application - Submit online
  2. Application Fee of $100.00 - Pay by credit or debit card. All application fees are nonrefundable.
  3. Criminal Background Check
  4. Verification of State Licensure(s) - Current license verification is required.  The official license verification must be sent directly from the licensing authority to the Board at pla3@pla.in.gov. If licensee holds more than one license, all license verifications are required to be submitted by licensee's first renewal.
  5. Supervising Physician - A supervising physician must have a current Indiana MD/DO license. License number of supervising physician must be provided at time of application.
  6. Practice Protocol Agreement - Supervising physicians (or primary supervising physician of a physician group practice) must submit a practice protocol agreement that details the exact privileges and tasks the anesthesiologist assistant shall be performing under the physician's supervision. In addition, please give a detailed description of the process maintained for evaluation of the anesthesiologist assistant's performance. If you plan to attach a copy of the evaluation form to the agreement, you must specify in the agreement that you are doing so. This practice protocol agreement must be completely typed, on company letterhead, be person specific, and must include the anesthesiologist assistant's and supervising physician's name, (or primary supervising physician of a physician group practice),license numbers, the practice address, and be signed and dated by both the anesthesiologist assistant and the supervising physician, (or primary supervising physician of a physician group practice). If there are additional supervisors, their names and license numbers should be included as an addendum.

  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 circumstances 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.

  Please go to the Additional Information section for FAQs.

Renewal Instructions

• Renewal Information

  Renew online in the MyLicense One platform.

  • Anesthesiologist Assistant licenses expire October 31 of every odd-numbered year.
  • The renewal fee is $50.

Change/Addition of Supervising Physician

• Change/Addition Information

  If there is a change in employment or physician group practice, the anesthesiologist assistant needs to complete and submit the Change/Addition of Supervising Physician Application, and a new practice protocol.  Additional instructions concerning practice protocols can be found in the AA Practice Protocol Helpful Documents section of the Application Instructions.

  If additional supervisors are added at a current place of employment or physician group practice, and the practice protocol for the anesthesiologist assistant at that place of employment has been approved, the names of the additional supervisors can be added as an addendum to the practice protocol.  The anesthesiologist assistant will need to complete the Change/Addition of Supervising Physician Application, but does not need to submit a new practice protocol.

  Anesthesiologist assistants adding or changing supervisors may continue practicing while this application is being processed.

  • Change/Addition of Supervising Physician Application

• Anesthesiologist Assistant Applications/Renewals

  Anesthesiologist Assistant Fees	Fee	Penalty	Total
  Initial Application	$100	NA	$100
  Renewal	$50	NA	$50
  Reinstatement - Expired over three years Anesthesiologist Assistant	$150	NA	$150