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.

Submit the following with your online application:

1. Application Fee: $100.00 payable via credit or debit card.  Additional online processing fees apply.
2. Criminal Background Check
3. 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).
4. 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.
5. 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.
6. NCCAA Certification: Applicant must hold a current NCCAA certification. Verifications may be obtained through the National Commission for Certification of Anesthesiologist Assistants website at www.nccaa.org. Your NCCAA certification is not a license verification and can't be substituted for one.
7. Verification of other License(s): License verification is required from each U.S. state or Canadian province in which you hold or have held a healthcare-related license. The official license verification must be sent directly from the licensing authority to the Board at pla3@pla.in.gov.
8. Supervising Anesthesiologist Statement: State Form 57723, must be completed and signed by the supervising Physician.
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.
   • AA Practice Protocol Checklist
   • AA Practice Protocol Agreement Sample

Submit the following with your online application:

1. Application Fee of $100.00: Pay by credit or debit card. All application fees are nonrefundable.
2. Criminal Background Check
3. 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).
4. 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.
5. Supervising Physician: Must have a currently active Indiana licensed supervising Physician.
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.
   • AA Practice Protocol Checklist
   • AA Practice Protocol Agreement Sample
7. 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.

• Anesthesiologist Assistant licenses expire October 31 of every odd-numbered year.
• The renewal fee is $50.00.

Renewal notices are sent approximately ninety (90) days prior to the expiration date. License holders with valid e-mail addresses on file will be e-mailed the renewal notice. Those who do not have valid e-mail 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 e-mailed to a valid e-mail address or mailed, the duty of the Board has been performed.

If you have a positive response to any of the renewal questions, you must submit an explanation and supporting documents at the time of submission in order to proceed with your online renewal.

(*) If there is a change of Supervising Physician, you must also submit a Change/Additional Supervising Physician Form and an updated Practice Protocol Agreement separately (see Change/Addition of Supervising Physician).

Receipt Requests: Please allow up to one business day for your receipt for payment to be received following the completion of your renewal to the email address on file with your license(s).

If your Anesthesiologist Assistant license has expired for three (3) years or more, you must reinstate the license to practice.

To reinstate the license, please submit the following with your online Reinstatement application:

1. Reinstatement fee: $150, plus additional processing fees. All fees are nonrefundable and nontransferable.
2. Positive Response Documentation: If you answer "Yes" to any questions on the application, explain all details fully, including 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).
3. Work History: Provide work history since the expiration of your license.
4. Supervising Anesthesiologist Statement: State Form 57723 must be completed, signed, and dated by the supervising Physician.
5. 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.
   • AA Practice Protocol Checklist
   • AA Practice Protocol Agreement Sample
6. NCCAA Certification: Verifications may be obtained through the National Commission for Certification of Anesthesiologist Assistants website at www.nccaa.org.
7. Verification of Active license: The official license verification must be sent directly from the licensing authority to the Board at pla3@pla.in.gov.

Anesthesiologist Assistants (AA) must maintain an accurate practice protocol on file to keep their license active and compliant. All updates can be completed online using MyLicense One. 

Changing or Adding a Supervising Physician

If you change employers or join a new physician group practice, you must submit a Change/Addition of Supervising Physician Application and attach a new Practice Protocol.

• How to submit: Log into your account, locate your AA license, and select the Change Collaborator/CPA action item.

Adding Supervisor(s) at Your Current Employment or Physician Group

If you are adding new supervising physician(s) at your current employer or practice group, and your existing practice protocol for the same group/employer has already been approved,  you do not need a new practice protocol. Instead, you may submitted the new physician's information as an addendum to the existing protocol along with the Change/Addition of Supervising Physician Application.

Removing a Supervisor or Protocol

To remove supervising physician(s) and/or cancel/rescind a practice protocol without replacing a new one, you may use the Remove Collaborator action found under your license options in MyLicense One.

Important: Every application and its attached protocol or addendum must be specific to ONE (1) Anesthesiologist Assistant (AA). Documents containing information for multiple AAs are invalid and will be rejected.

To maintain an Active Anesthesiologist Assistant license, you must have at least one active practice protocol on file with an Actively Licensed Indiana Physician. Without an approved protocol, your AA license may be moved to an Expired status, regardless of the printed expiration date. 

If your AA license is placed on Expired status solely for lacking a protocol on file, you may reactivate it by submitting a Change/Addition Application with a new practice protocol through the Change Collaborator/CPA action and complete any other requirements as determined by the board.