Free 50025.FH11 - Indiana

APPLICATION FOR PRESCRIPTIVE AUTHORITY AS AN ADVANCED PRACTICE NURSE
State Form 50025 (R / 2-06) Approved by State Board of Accounts, 2006

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INDIANA STATE BOARD OF NURSING PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2043 E-mail: [email protected]

INSTRUCTIONS:

Please type or print clearly.

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

FOR OFFICE USE ONLY
Application fee Prescriptive authority number Date fee paid (month, day, year) Receipt number

Date of issuance (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Please check one of the following indicating the category of Advanced Practice Nurse:

Clinical Nurse Specialist
Area of practice / specialty:

Nurse Practitioner

Certified Nurse Midwife

APPLICANT INFORMATION
Name (last, first, middle, maiden) (include any names EVER used) Address (number and street or rural route, city, state, and ZIP code) Date of birth (month, day, year) Social Security number * E-mail address Place of birth (city and state) Telephone number (include area code)

(

)

NUMBER AND STREET

LIST ALL CURRENT OFFICE ADDRESSES & TELEPHONE NUMBERS CITY STATE ZIP CODE

TELEPHONE NUMBER

( ( ( ( ( (
LIST ALL NURSING EDUCATION LOCATION

) ) ) ) ) )

NAME OF SCHOOL

DATES ATTENDED

DEGREE(S) GRANTED

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LIST ALL NAMES AND ADDRESSES OF EMPLOYERS AND RESPONSIBILITIES HELD OR PERFORMED SINCE GRADUATION FROM NURSING SCHOOL

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED, CERTIFIED, OR REGISTERED TO PRACTICE ANY REGULATED HEALTH OCCUPATION STATE PROFESSION NUMBER ISSUED DATE ISSUED STATUS

LIST THE NAME AND LICENSE NUMBER OF THE COLLABORIATING PHYSICIAN(S) Name License Number

If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation of the prescriptive authority issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held in any state or country? 2. Have you ever been denied a license, certificate, registration or permit to practice as a nurse or any regulated health occupation in any state or country? 3. Are there charges pending against you regarding a violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? 4. Have you ever been convicted of, pled guilty or nolo contendre to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? B. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as a nurse or as another health care professional? 6. Have you ever had a malpractice judgment against you or settled any malpractice action? 7. Are you now, or have you ever been treated for drug or alcohol abuse? Yes No Yes Yes Yes No No No

Yes Yes Yes Yes

No No No No

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)

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AUTHORIZATION TO RELEASE 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 prescriptive authority as an Advanced Practice Nurse. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any information. I further authorize the Professional Licensing Agency to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Indiana State Board of Nursing 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 the same.
Signature of applicant Date (month, day, year)

PLEASE TAPE YOUR PHOTOGRAPH BELOW (You must place your signature on the front of your photograph.)

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