Application & Instructions

AA Practice Protocol Checklist
AA Practice Protocol Agreement Sample

Documents Required for Licensure

1. Completed Application - Application for Licensure as an Anesthesiologist Assistant
2. Photograph - passport quality photo taken within the past eight (8) weeks
3. Application Fee - $100 in the form of a check or money order to the Indiana Professional Licensing Agency
4. Official Transcript - sent directly from the institution of higher learning where the applicant received a baccalaureate degree
5. Official Transcript - sent directly from the approved anesthesiologist assistant education program where the applicant received a degree, including the degree conferred and the date of graduation
6. Verification from the National Commission for Certification of Anesthesiologist Assistant (NCCAA) of the applicant's certification status
7. Verification of other state licenses - an applicant who currently holds, or has previously held, a license, certification, or registration issued by another state to practice any health profession must request verification of license status from the state that issued that license, certification, or registration. The verification must be sent directly to the board from the agency that issued the license,  certification, or registration. Official electronic verification will also be accepted.
8. Practice Protocol Agreement- (see the  "AA Practice Protocol Checklist" at the top of this page for more clarification of the agreement requirements) 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.     You may receive a license without a practice protocol submitted; however, the Board is currently reviewing all practice protocols.  You may not practice until the protocol is approved. 
9. Name Change Documentation (if applicable) - If your name has changed or differs on any documents submitted, please include an official name change document such as a marriage license or divorce decree.
10. Criminal Background Check - An applicant will receive an email from their respective board with the official date the application was processed.  Fingerprints must be submitted on or after the date of this email notice for the CBC to be considered valid and timely.  CBCs conducted prior to the email notice date will not be considered. Please review our criminal background check webpage for more information.

Positive Response

If you have answered any of the questions on the application “yes” you must submit a notarized affidavit detailing the occurrence/situation, the outcome, date of occurrence, if it is a malpractice payment the amount paid in your behalf.  If applicable please submit copies of all court documents and/or arrest records. Letters from attorneys or insurance companies are not accepted in lieu of your statement.