Free 17598.FH11 - Indiana

APPLICATION FOR A TEMPORARY MEDICAL PERMIT (For Postgraduate Training, Teaching, or Fellowship)
State Form 17598 (R10 / 3-07) Approved by State Board of Accounts, 2007

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MEDICAL LICENSING BOARD OF INDIANA PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2060 E-mail: [email protected] www.pla.IN.gov

* 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. ** This information is being requested for workforce statistical purposes only; disclosure is voluntary.

FOR OFFICE USE ONLY
Permit fee Permit number Date fee paid (month, day, year) Receipt number

Permit issuance date (month, day, year)

Applicant Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

Applying for:
Name of applicant (last, first, middle)

Postgraduate training APPLICANT INFORMATION

Teaching

Fellowship

Social Security number *

Address of practice (number and street or rural route) City, state, and ZIP code Telephone number (daytime) Date of birth (month, day, year) Ethnicity ** Race ** Gender **

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Male

Female

Please indicate what address you want your permit sent to (number and street or rural route) [if different than above] City, state, and ZIP code Email address National Practitioner Identifier number

Name of school

DOCTOR OF MEDICINE / OSTEOPATHIC DEGREE GRANTED BY
Location Date of graduation (month, day, year)

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

NAME OF SCHOOL

PRE-MEDICAL / OSTEOPATHIC EDUCATION LOCATION

DATES ATTENDED (month, day, year)

MEDICAL / OSTEOPATHIC EDUCATION A foreign medical school must meet LCME standards at the time of graduation. NAME OF SCHOOL LOCATION DATES ATTENDED (month, day, year)

POSTGRADUATE MEDICAL / OSTEOPATHIC EDUCATION AND TRAINING IN THE UNITED STATES OR CANADA (Include ALL internships, residencies and / or fellowships) All programs must have been ACGME accredited at the time of enrollment. NAME OF SCHOOL LOCATION FROM (month, year) TO (month, year) ACGME ACCREDITED? Yes Yes Yes Page 1 of 3 No No No

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM MEDICAL OR OSTEOPATHIC SCHOOL DATE (month, day, year) GENERAL LOCATION

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM MEDICAL OR OSTEOPATHIC SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATE (month, day, year)

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE ANY REGULATED HEALTH OCCUPATION STATE TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT NUMBER DATE ISSUED CURRENT STATUS

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s), case information, detailed description of the case / events and settlement amount, including court documents, if applicable. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following, is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any license, certificate, registration or permit you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice osteopathic medicine or any regulated health occupation in any state (including Indiana) or country, or surrendered your license? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been the subject of an investigation by a regulatory agency concerning your license? 5. Have you ever been arrested, convicted of, pled guilty or nolo contendere to, or are formal charges pending: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substance or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor traffic laws resulting in fines.) 6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 8. Have you ever had a malpractice judgment against you or settled any malpractice action? 9. Have you surrendered your DEA registration at any time or had any limitations placed on your DEA registration? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes

No No No No

Yes Yes Yes Yes Yes Yes

No No No No No No

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned, requested by the Agency or any of its authorized representatives in connection with processing my application for temporary medical permit. I hereby release the aforementioned persons, firms, officers, corporations, association, organization, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency and Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Date signed (month, day, year) Signature of applicant

HOSPITAL / INSTITUTION CERTIFICATION FOR A TEMPORARY MEDICAL PERMIT OR A TEMPORARY MEDICAL TEACHING PERMIT (to be completed by the hospital / institution Chairman / Department Head)

This is to certify that ________________________________________________________________________ has been granted an appointment to serve at ______________________________________________________________________________ in the Department of ________________________________________________________________________________________ located at (address) ______________________________________________________________________________________ this appointment is for the month and year beginning _________________________ and ending _________________________
Name of Hospital Chairman/Department Head Signature Title Date of signature (month, day, year) Telephone number

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