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APPLICATION FOR A NON-RENEWABLE LIMITED

Health Professions Bureau

402 W. Washington St., Rm. 041

SCOPE TEMPORARY MEDICAL PERMIT

Indianapolis, IN 46204

Your Social Security Number is being requested by this

Telephone: (317) 234-2060

State Form 26138 (R4 / 10-02)

state agency in accordance with IC 4-1-8-1. Disclosure

Approved by State Board of Accounts, 2002

is mandatory, and this record cannot be processed without it.

REQUIREMENTS AND INSTRUCTIONS TO THE APPLICANT

A. Mail completed application, along with items listed below, to the Health Professions Bureau:

1. FEE - Submit the one hundred dollar ($100) fee made payable to the Health Professions Bureau. Fees are

non-refundable and non-transferable.

2. PHOTOGRAPH - Attach one (1) passport type quality photograph of your self taken within the last eight weeks.

3. PROOF OF GRADUATION - You may submit proof of graduation by submitting one of the following documents:

(a) OFFICIAL TRANSCRIPT An official transcript of grades from the medical / osteopathic school, showing degree has been

conferred. Graduates of foreign medical schools must submit notarized copies of all subjects and grades (mark sheets). Include

official translation if not in english. (SEE NOTARIZED COPY NOTE)

(b) DEGREE A notarized copy of your medical / osteopathic degree. Include official translation if not in english. (SEE NOTARIZED

COPY NOTE)

4. PROOF OF CURRENT LICENSE - Provide proof of current licensure in another state. A notarized copy of your current license

(billfold license or pocketcard) which shows your license number and expiration date will be acceptable.

PERMITS ARE NOT AVAILABLE ON A WALK-IN BASIS FROM THE BUREAU. NO EXCEPTIONS.

NOTE: A Non-Renewable, Limited Scope, Temporary Permit May be Issued to an Applicant Only Once. THIS PERMIT IS

VALID FOR A NON-RENEWABLE PERIOD OF NO MORE THAN THIRTY (30) DAYS.

NOTARIZED COPY NOTE: Any notarized copy of an original document must have the notary public make a statement of the

fact that the notary has seen the original document.

THE NON-RENEWABLE, LIMITED SCOPE, TEMPORARY MEDICAL PERMIT SHALL BE LIMITED TO A SPECIFIC ACTIVITY, FUNCTION,

SERIES OF EVENTS OR PURPOSE, AND TO A SPECIFIC GEOGRAPHIC AREA WITHIN THE STATE, WHICH LIMITATIONS SHALL BE

STATED ON THE FACE OF THE PERMIT. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO CONTACT THIS OFFICE.

OFFICE USE ONLY

Permit fee

Date fee paid (month, day, year)

Receipt number

Permit issuance date (month, day, year)

Permit number

Applicant

Attach one (1) passport type

APPLICANT INFORMATION

quality photograph of yourself

Name of applicant

Social Security number

taken within the last eight weeks.

Address (number and street or Rural Route number)

City, state, ZIP code

Telephone number (daytime)

Date of birth (month, day, year)

Place of birth

(

)

E-mail address

SPECIFICATION AND IDENTIFICATION

Specify reasons for seeking this permit

Specify type, extent , and specilization medical services to be provided

Specify specific location and exact dates that the above services will be provided.

Location:

From:

To :

(Continued on reverse side)

State Form 26138 - Application For A Non-Renewable Limited Scope Temporary Medical Permit - Indiana

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