Application Instructions

• Application and Instructions for Licensure as a Physician Assistant

  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: Submit online
  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).
  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.
  6. Official Transcript: Submit an official transcript of courses and grades from an approved Physician Assistant school showing that the degree has been confirmed.
  7. Copy of Diploma: An original copy of your diploma.
  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.
  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 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.

  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

• Temporary Permit

  For applicants applying by Examination or Endorsement.  Applicants are not eligible for a temporary permit when applying by credentials.

  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.  The temporary permit is only good while the Committee members are reviewing your full application.

  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.

  1. Temporary Permit Request: Submit online after you have submitted your primary application for Physician Assistant.
  2. Application fee of $50.00: Pay by credit or debit card. Please note that this fee is in addition to the $100.00 Physician Assistant application fee for a total of $150.00.  All application fees are nonrefundable.
  3. All Requirements for full licensure (including the passage of the examination) and is awaiting the next schedule meeting of the committee.
• Documents Required for Prescriptive Authority
  • Application: The initial application submitted for a Physician Assistant will include the request for Prescriptive Authority.  If you are not yet prepared to request the Prescriptive Authority at the time of application for full licensure, you will be required to use the Change or Addition of Collaborative Physician section below.
  • You must also submit a controlled substance registration application and fee if you will be prescribing controlled substances - see below.
  • Collaborative Agreement - The agreement must meet the requirements stated in IC 25-27.5-5-2.  The Collaborating Physician shall submit a description of the exact privileges and tasks the physician assistant shall be performing under the physician’s collaboration.  The collaborating agreement shall be specific to the physician assistant being hired “i.e. John Brown, PA will be responsible for…”  Also include a description of procedures for dealing with emergencies.  The collaborative agreement must be completely typed, on letterhead, and signed by both the physician and physician assistant.  The collaborative agreement must also include a list of classifications of medications the physician assistant is delegated to prescribe (example:  May prescribe schedules II - V)  and a 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.  All prescribing sections in an agreement must include the following statement:  The PA may not prescribe schedule I.

  If you are seeking to prescribe non-controlled substances, you must specifically state this in your agreement.  Example:  "The physician assistant will only be prescribing non-controlled substances."

  • Collaborative Agreement Checklist
  • Collaborative Agreement Sample

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

  Chart Review

  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 Mary 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

• Instructions for Change or Addition of Collaborative Physician

  Change and Addition of Collaborating Physician Application

  Documents Required

  The Physician Assistant  must complete, date and sign the application and return it by U.S. Mail 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.
  • Collaborative Agreement - The section above provides instructions and examples for the Collaborative Agreement.
• Information Regarding Reciprocity

  Licensure by Reciprocity: The Committee shall issue a license to an applicant if the applicant satisfies the following conditions:
  PLEASE NOTE THAT YOU CANNOT WORK WITH A LICENSE ISSUED BY RECIPROCITY UNTIL YOU HAVE A COLLABORATING AGREEMENT FILED AND APPROVED BY THE COMMITTEE. 
  * Holds a current license from another state or jurisdiction; and
  *that state's or jurisdiction's requirements for a license are substantially equivalent to or exceed the requirements for a license of the Committee; or
  *when the person was licensed or certified by another state:

  • there were minimum education requirements in the other state or jurisdiction;
  • if there were applicable work experience and clinical supervision requirements in effect, the person met those requirements to be licensed in that state; and
  • if required by the other state or jurisdiction, the person previously passed an examination required for the license or certification.

  • • Has not committed any act in any state or jurisdiction that would have constituted grounds for refusal, suspension, or revocation of a license, certificate, registration, or permit to practice that occupation in Indiana at the time the act was committed.
    • Does not have a complaint or an investigation pending before the regulating agency in another state or jurisdiction that relates to unprofessional conduct.
    • Is in good standing and has not been disciplined by the agency that has authority to issue the license or certification.
    • If a law regulating the applicant's occupation requires the Committee to administer an examination on the relevant laws of Indiana, the Committee may require the applicant to take and pass an examination specific to the laws of Indiana.
    • Pays any fees required by the Committee for which the applicant is seeking licensure.
• Controlled Substance Registration

  For controlled substances, if you already have authority to prescribe legend drugs, you will need to submit an updated practice agreement indicating your authority to prescribe controlled substances with the CSR.  If you have more than one practice location, you will only need a separate CSR for locations in which you administer and/or dispense controlled substances.  If you just prescribe controlled substances, you only need a Controlled Substance Registration at your main location.

  Go to https://www.in.gov/pla/professions/controlled-substance-registration/ for application and instructions.

Renewal Instructions

• Renewal Information
  • 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.
  • 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 after 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 Change CSR Location via your MyLicense One account using the Change CSR Location Action, 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.

• Activation of Inactive License

  To renew from Inactive status back to Active status, you must submit the following:

  • Renewal Form for Physician Assistant Inactive to Active
  • Inactive to Active Renewal Fee: $25.00 by check or money order made out to Indiana Professional Licensing Agency
  • This can be done in conjunction with submitting a change/addition application, fee, and new collaborative agreement. Instructions above.
• Reinstatement Information

  Expired less than 3 years

  Licenses that are expired less than 3 years may renew online using MyLicense One and will incur the late fee.

  Expired Three (3) Years or more

  If your Physician Assistant license has been expired for three or more years, you must reinstate your license to practice.  Please submit your reinstatement online with the additional documentation:

  • Reinstate Online!
  • Payment of the current renewal fee ($50) and current initial application fee ($100).  Total reinstatement fee:  $150.
  • Documentation to Upload:
    • Letter of work history or resume detailing your work since your license expired
    • Verifications of licensure of all licenses held in any and all states
    • Copy of proof of current NCCPA

  If your CSR-Physician Assistant has been expired for three or more years, you must reinstate your license to practice.

  • Reinstate Online!
  • Payment of the current renewal fee ($60) and current initial application fee ($60).  Total reinstatement fee:  $120.
  • Documentation to Upload:
    • Copies of certificate of completion in two hours of continuing education in opioid abuse and prescribing to obtain or renew the registration. The two hours must be obtained within the previous two years prior to applying for or renewing a registration.

Fee Schedule

• Physician Assistant Applications/Renewals

  Physician Assistant Application/Renewal	Fee
  Initial Application (with Temporary Permit)	$150.00
  Change of Supervising Physician	$50.00
  Addition of Supervising Physician	$50.00
  Renewal - due 6/30 of even-numbered years	$50.00
  Controlled Substance Registration	$60.00
  Inactive Status	$25.00

• FAQs

  1.      If a PA is applying for prescriptive authority and they are going to have more than one collaborating physician at the facility do they need to submit a prescriptive authority application for each physician?

  • No, you need to only submit one application; however, include additional copies of page 3 of the application with each physician's information.

  2.      If you have more than one collaborating physician do you have to submit separate collaborative agreements?

  • If you have more than one collaborating physician and you will be performing the same duties with each physician they may all be in one agreement.
  • If you are performing separate duties for each physician then a separate agreement should be submitted for each physician.

  3.      If I am going to practice at two separate locations for two separate physicians do I need to complete two prescriptive authority applications?

  • No, you do not need to submit more than one prescriptive authority application. You would submit one prescriptive authority application with one physician.  You would then need to complete Change/Addition Applications for every other collaborating physician.  All collaborative agreements will need to include prescriptive authority in the agreement to prescribe.

  4.      Once I have prescriptive authority do I have it indefinitely or do I have to reapply each time I change supervising physicians?

  • You only need to apply for prescriptive authority once. If you change or add collaborating physicians, you need to complete a Change and/or Addition application along with the collaborative agreement that includes the authority to prescribe within the new practice.

  5.      Must I submit an application for a Controlled Substance Registration (CSR)?

  • You only need to submit an application for a CSR for your place of employment if you are prescribing, administering or dispensing controlled substances.  It is not necessary if you are only prescribing legend drugs.  If you have more than one office, you must apply for a CSR at each location in which you are dispensing or administering controlled substances.  One CSR will cover multiple locations for prescribing.

  6.      How long will it take to obtain my prescriptive authority?

  • The time will first depend on how long it takes the applicant to submit all documents required.
  • The application is then subject to the review and approval of the Physician Assistant Committee.

  7.      Must I renew the prescriptive authority with my PA license?

  • Prescriptive authority is not a renewable status.  Once you are issued prescriptive authority your status will say Physician Assistant-Prescriptive Authority.  You will only need to renew your PA license and any CSR’s you have in June of even years.

  8.      Where I presently work, I do not prescribe, but I will be prescribing at my new place of employment. What do I need to submit?

  • You will need to submit the Change and Addition application and all requirements for it.
  • You will also need to submit the Prescriptive Authority application and all requirements for it with the following exceptions:
    • You are required to only submit one collaborative agreement (same one can be used for both applications as long as the applications are submitted at the same time).
    • You will also need to submit a CSR application and all requirements for it if you will be prescribing controlled substances.

  10.  What needs to be included in the Collaborative Agreement?

  • Please review the collaborative agreement sample.

  11.  Can I practice as soon as you receive my application?

  • If it is an initial application to practice as a physician assistant, you cannot practice until a license is issued and a collaborative agreement is on file.
  • If it is an application for prescriptive authority, you may practice with your collaborating physician as a PA (assuming you are licensed); however, you cannot practice using the prescriptive authority until you receive an approval letter from the Board.
  • You have thirty (30) days after beginning a practice with a new or additional collaborating physician to complete a Change/Addition Application.

  12.  IC 25-27.5-5-2(f)(4) states that the supervisory agreement must specify the name of the drug or drug classification being delegated to the PA and the protocol the PA shall follow in prescribing a drug. What does Protocol mean?

  • Protocols are the instructions that the PA shall follow in prescribing a drug.

  13.   Can I write a prescription for a Schedule II controlled substance?   

  • Yes, if your collaborative agreement and CSR permits you to.
  • If your current collaborative agreement does not permit you to prescribed Schedule II controlled substances, you may have the agreement amended and submitted to the Committee for approval.