Fillable Printable Form 50025
Fillable Printable Form 50025
Form 50025
APPLICATION FOR PRESCRIPTIVE AUTHORITY
AS AN ADVANCED PRACTICE NURSE
State Form 50025 (R6 / 9-17)
Approved by State Board of Accounts, 2017
Application fee
FOR OFFICE USE ONLY
Date fee paid (month, day, year)
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)
Place of birth (city and state)
* 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.
Telephone number (include area code)
NAME OF SCHOOL LOCATION DATES ATTENDED DEGREE(S) GRANTED
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Please check one of the following indicating the category of Advanced Practice Nurse:
Clinical Nurse Specialist Nurse Practitioner Certified Nurse Midwife Certified Registered Nurse Anesthetist
Area of practice / specialty
NUMBER AND STREET CITY STATE ZIP CODE TELEPHONE NUMBER
( )
Receipt number
Prescriptive authority number Date of issuance (month, day, year)
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]
www.pla.IN.gov
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
LIST ALL CURRENT OFFICE ADDRESSES & TELEPHONE NUMBERS
LIST ALL NURSING EDUCATION
( )
( )
( )
( )
( )
Please check the box to be included on the Health Care Volunteer Registry established by IC 25-22.5-15. (Optional)
Social Security number*
E-mail address
INSTRUCTIONS: 1. The fee for this application is $50.00, payable to the Indiana Professional Licensing Agency, in accordance with 848 IAC 5-3-1.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
Are you the spouse of a member of the military who is assigned to a duty station in Indiana? (Optional)
Yes No
Are you an active duty member of the military? (Optional)
Yes No
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
Reset Form
STATE PROFESSION NUMBER ISSUED
DATE ISSUED
(month, day, year)
STATUS
NAME
LICENSE NUMBER
I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Date (month, day, year)Signature of applicant
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
LIST THE NAME AND LICENSE NUMBER OF THE COLLABORATING PHYSICIAN(S)
APPLICATION AFFIRMATION
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6. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left
untreated may interfere, with your ability to practice in a competent and professional manner?
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. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony
in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
4. Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as a
nurse or as another health care professional?
5. Have you ever had a malpractice judgment against you or settled any malpractice action?
Yes No
Yes No
Yes No
Yes No
Yes No
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation
of the license or permit issued pursuant to this application.
Yes No
Yes No
Yes No
Yes No
Yes No
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.
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.)
AUTHORIZATION TO RELEASE INFORMATION
AFFIRMATION
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