410 IAC 36-2-4 Miscellaneous provisions

Sec. 4. (a) The application shall not be accepted by the department unless all portions of the application form are completely filled out. Failure to complete the application properly shall result in the application being denied. (b) The application is valid for a period of three (3) months from the date of signature of the health care provider. (c) Completed application forms will be maintained at the department. (d) To obtain a replacement card, applicants must submit a new application and pay the accompanying fee of five dollars ($5).