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Medical Examiners Chapter 1/Appendix A
Supp. 12/31/18 A-1
ALABAMA STATE BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
APPENDICES
TABLE OF CONTENTS
Chapter 1
Commence Of Collaborative Practice ................. Appendix A
Collaborative Practice Registration Renewal ........ Appendix B
(Repealed 9/2/18)
Chapter 3
Application For Certificate Of Qualification To
Practice Medicine In Alabama..................... Appendix A
Application For A Limited Certificate Of
Qualification.................................... Appendix B
Application For A Certificate Of Qualification
Under The Retired Senior Volunteer Physician
Program (RSVP)................................... Appendix C
Retired Senior Volunteer Program Certificate Of
Qualification Renewal Application................ Appendix D
Limited Certificate Of Qualification Renewal
Application...................................... Appendix E
Application For Reinstatement Of Certificate Of
Qualification.................................... Appendix F
Chapter 4
Application For Controlled Substance
Registration Certificate......................... Appendix A
Alabama Controlled Substance Certificate
Registration Renewal............................. Appendix B
Dispensing Physician’s Registration Form ........... Appendix C
Chapter 7
Application For Registration Of Physician
Assistant........................................ Appendix A
Application For Licensure Of Physician Assistant ... Appendix B
Application For Registration Of Anesthesiologist
Assistant........................................ Appendix C
Application For Licensure Of Anesthesiologist
Assistant........................................ Appendix D
Chapter 1/Appendix A Medical Examiners
Supp. 12/31/18 A-2
Physician Assistant/Anesthesiologist Assistant
License Renewal.................................. Appendix E
Application For Reinstatement Of Physician
Assistant/Anesthesiologist Assistant License..... Appendix F
Chapter 11 (Repealed Effective 6/24/96)
Initial Survey Of Foreign Medical Schools By The
Alabama Board Of Medical Examiners............... Appendix A
Descriptive Data On A Foreign Medical School ....... Appendix B
Standards For Approval Of Foreign Medical
Schools.......................................... Appendix C
Procedures For The Site Visit And The Site Visit
Team............................................. Appendix D
Chapter 16
Application For Certificate Of Qualification For
A Special Purpose License To Practice Medicine
Or Osteopathy.................................... Appendix A
Medical Examiners Chapter 540-X-1, Appendix A
Supp. 12/31/18 A-3
ALABAMA BOARD OF MEDICAL EXAMINERS
Application: Commencement of Collaborative Practice
Under Alabama law, this document is a public record and if requested
it will be provided in its entirety.
Physician’s Name/License Number
Physician’s primary practice specialty
Physician’s primary practice address
CRNP/CNM Name/RN License Number
Certification specialty
CRNP/CNM Primary practice address
Number of hours per week to practice in this Collaborative Agreement
Cumulative total hours for CRNPs, CNMs and PAs may not exceed 160
hrs/week for each physician)
The physician’s signature/electronic signature certifies that I the
undersigned physician agree and/or confirm:
1. I have read and understand my responsibilities according to
the Alabama Board of Medical Examiners Rules, Administrative
Rules Chapter 540-X-8, Advanced Practice Nursing:
Collaborative Practice.
2. All covering physician(s) listed in the application have
knowledge and understanding of the Alabama Board of Medical
Examiners Rules, Administrative Rules Chapter 540-X-8,
Advanced Practice Nursing: Collaborative Practice, and are
aware of their responsibilities in this Collaborative
Agreement.
3. Attest to understanding of the Quality Assurance
Documentation requirement:
a. Documented Quality Assurance Reviews are required no less
than quarterly and shall be readily retrievable.
b. Physician and CRNP or CNM must review Quality Assurance data
together.
c. My signature on a patient record does not constitute Quality
Assurance documentation.
I understand and agree that by typing my name, I am providing an
electronic signature that has the same legal effect as a written
signature pursuant to Ala. Code §§8-1A-2 and 8-1A-7. I attest that
the foregoing information has been provided by me and is true and
correct to the best of my knowledge, information and belief.
Chapter 540-X-1, Appendix A Medical Examiners
Supp. 12/31/18 A-4
Knowingly providing false information to the Alabama Board of Medical
Examiners could result in disciplinary action.
PHYSICIAN’S SIGNATURE DATE
Fee for commencement of collaborative practice: $200
Author: Alabama State Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §34-24-53, Act 2007-402.
History: New Rule Appendix: Filed November 13, 2007; effective
December 18, 2007. Amended: Filed October 21, 2010; effective
November 25, 2010. Amended: Filed May 21, 2015; effective
June 25, 2015. Repealed and New Rule: Filed January 24, 2018;
effective March 10, 2018. Amended: Filed July 19, 2018;
effective September 2, 2018.
Medical Examiners Chapter 1/Appendix B
Supp. 12/31/18 A-5
Collaborative Practice Registration Renewal
(Repealed 9/2/18)
Author: Alabama State Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §34-24-53, Act 2007-402.
History: New Rule: Filed May 21, 2015; effective June 25, 2015.
Repealed and New Rule: Filed July 20, 2017; effective
September 3, 2017. Repealed: Filed July 19, 2018; effective
September 2, 2018.
Chapter 3 - Appendix A Medical Examiners
Supp. 6/30/19 A-6
ALABAMA STATE BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 – APPENDIX A
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116
APPLICATION FOR CERTIFICATE OF QUALIFICATION TO
PRACTICE MEDICINE IN ALABAMA
Under Alabama law, this document is a public record and will be provided upon request.
To the Alabama Board of Medical Examiners:
I hereby make application for a certificate to practice medicine in the State of Alabama, and submit the
following statement concerning my age, moral character, preliminary and medical education and
practice:
Name in Full
Social Security Number #
** Social Security Number (Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that
you provide your social security number (SSN) on this application. The uses of your SSN are limited to
the purpose of administering the state child support program and intra-agency for identification purposes.
If your SSN is not provided, your application is not complete and no license will be issued)
Place of Birth
Country of Birth
City of Birth
State/Province of Birth
Gender/Sex (at birth)
Date of Birth
Contact Information
The address and contact methods provided should be how the Board or Commission can contact the
license applicant directly. Please DO NOT provide contact information for office managers, assistants, or
license assistance companies.
Address
Contact Methods
Email Address
Home Telephone Number
Work Telephone Number
Medical Examiners Chapter 3/Appendix A
Supp. 6/30/19 A-7
Answer yes or no (if any following answers are in the affirmative, please explain in detail and
provide the complete name and address of any state board, hospital, psychiatrist/psychologist,
etc.):
1. Have you ever been convicted of a felony? (You answered Yes, please
provide the name of the court of record or a copy of the record of
conviction)
2. Have you ever been convicted of a crime or offense (felony or
misdemeanor) related to the practice of medicine? (If yes, please provide
the name of the court of record or a copy of the record of conviction)
3. Have you ever been convicted of any violation of a state or federal law
relating to controlled substances? (If yes, please provide the name of the
court of record or a copy of the record of conviction)
4. Have you ever been denied a state or federal controlled substance
certificate?
5. Has your certificate of qualification or license to practice medicine in any
state been suspended, revoked, restricted, curtailed, or voluntarily
surrendered under threat of suspension or revocation?
6. Have your staff privileges at any hospital or health care facility been
revoked, suspended, curtailed, limited, or placed under conditions
restricting your practice?
7. Have you ever been denied a certificate of qualification or a license to
practice medicine in any state or has your application for a certificate of
qualification or license to practice medicine been withdrawn under threat
of denial?
8. Have you ever had a judgment rendered against you, or action settled
relating to performance of your professional service?
9. To your knowledge, are you the subject of an investigation by any
licensing board/agency as of the date of this application?
10. Within the past five years, have you ever raised the issue of consumption
of drugs or alcohol or the issue of a mental, emotional, nervous, or
behavioral disorder or condition as a defense, mitigation, or explanation
for your actions in the course of any administrative or judicial proceeding
or investigation; any inquiry or other proceeding; or any proposed
termination by an educational institution; employer; government agency;
professional organization; or licensing authority?
11. Have you ever been diagnosed as having or have you ever been treated
for pedophilia, exhibitionism, or voyeurism?
12. Are you currently* engaged in the excessive use of alcohol, controlled
substances, or the use of illegal drugs, or received any therapy or treatment
for alcohol or drug use, sexual boundary issues or mental health issues? (If
you are an anonymous participant in the Alabama Physician Health
Program and are in compliance with your contract, you may answer “no”
to this question, such answer for this purpose will not be deemed upon
certification as providing false information to the Alabama Board of
Chapter 3 - Appendix A Medical Examiners
Supp. 6/30/19 A-8
Medical Examiners or the Medical Licensure Commission of Alabama)
You answered Yes, a description is required.
IMPORTANT: The Board recognizes that licensees encounter health
conditions, including those involving mental health and substance use disorders,
just as their patients and other health care providers do. The Board expects its
licensees to address their health concerns and ensure patient safety. Options
include anonymously self-referring to the Alabama Physician Health Program
(334-954-2596), a physician advocacy organization dedicated to improving the
health and wellness of medical professionals in a confidential manner. The
failure to adequately address a health condition, where the licensee is unable to
practice medicine with reasonable skill and safety to patients, can result in the
Board taking action against the license to practice medicine.
Please initial certifying that you understand and acknowledge your duty as a licensee to
address any such condition as stated above.
13. Within the past five years, have you been convicted of driving under
the influence (DUI) or have you been charged with DUI and been
convicted of a lesser offense such as reckless driving?
14. Has your medical training or medical practice been interrupted or
suspended for a period longer than 60 days for any reason other than a
vacation?
15. Have you ever been placed on academic or disciplinary probation by a
medical school or postgraduate program?
16. Have you ever been disciplined for unprofessional conduct/behavior
reasons by a medical school or postgraduate program?
17. Were you notified in writing that there were limitations or special
requirements imposed on you because of questions of academic or
clinical incompetence, disciplinary problems, or any other reason during
your medical education or postgraduate training?
Please provide the following information:
City of intended residence in Alabama*
*Please enter the City where you intend to live in Alabama. If you will be living outside of Alabama please type “Out of State” in the field.
Education Information
When entering dates attended in the education sections if you don’t know the exact date use the first date of the month. (Example: you attended from August 1990 – July 1994, Enter 08/01/1990 – 07/01/1994)
Pre-Medical Education
List all schools attended, undergraduate work other than medical school, dates, attended, and degree conferred.
School Name
Medical Examiners Chapter 3/Appendix A
Supp. 6/30/19 A-9
State Date
End Date
Degree Received
Medical Education
List all medical Schools attended, dates, and complete addresses of institutions. Do not list post-graduate medical education training.
Medical School Name
Start Date
End Date
Street Address
Suite
City
State
Zip
Country
Post-graduate Medical Education Training
List all post-graduate medical education training since graduation from medical school, dates, and complete address of institutions. DO NOT list practice experience.
Facility Name
Start Date
End Date
Street Address
Suite
City
State
Zip
Country
Activities following Medical School and Training
List all practice experience since completion of your formal training, providing dates,
institutions/hospitals, and complete addresses.
Facility/Hospital Name
Start Date
End Date
Chapter 3 - Appendix A Medical Examiners
Supp. 6/30/19 A-10
Street Address
Suite
City
State
Zip
Country
Hospital Privileges
List all hospitals where you have held staff privileges of any type, providing dates, hospital names and
complete addresses.
Hospital Name
Start Date
End Date
Street Address
Suite
City
State
Zip
Country
Please explain for period of time unaccounted for
License Information
Specialty(s): (Choose from list)
Specialty Board Certification: Are you CURRENTLY certified by one of the specialty boards approved
by the American Board of Medical Specialties or the American Osteopathic Association?
You answered Yes, have your specialty board send verification to the Alabama Board of Medical
Examiners.
Please List your Specialty Board Certification(s)
Have you ever been issued a full unrestricted medical license in another State? (Please exclude any
limited licenses or training permits)
Original Full License
It is a requirement that the original state of issue will have to provide a written verification directly to the
Board.
Please provide the following information on the first original medical license received.
State that issued the original first license
Date original first license was issued
Original first license number
Examination taken to receive original first license
Medical Examiners Chapter 3/Appendix A
Supp. 6/30/19 A-11
Has this license been the subject of any disciplinary action?
You answered yes, please provide a summary and supporting documentation
State Licensure
List all states where you have been licensed to practice medicine. It is a requirement that each state
provide a written verification directly to the Board. List all licenses including training or educational
licenses. Please Note: training and education licenses do not require a written verification.
State
Type of License
SPEX Requirement:
Have you been certified or re-certified within the past ten years by one of the specialty boards approved
by the American Board of Medical Specialties or the American Osteopathic Association?
Have you successfully completed a written licensing examination within the last ten years?
What was the date the written licensing examination was taken?
Please select the licensing examination you have taken within the last ten years:
USMLE
Date initially passed Step 1:
Number of attempts to pass Step 1:
If you took Step 2 before it was split into two parts enter you attempts in Step CS and Enter 0 (zero) in
Step 2 CK.
Number of attempts to pass Step 2 CS:
Number of attempts to pass Step 2 CK:
Number of attempts to pass Step 3:
Date initially passed Step 3:
According to the information provided the applicant does not qualify for a certificate of qualification
(COQ) to practice medicine in the state of Alabama without taking and passing the SPEX. If the
applicant would like to continue with the application process once the board is in receipt of all required
information and the application is considered complete the Alabama Board of Medical Examiners will
endorse the applicant for the SPEX. NOTE: The applicant will have 1 year from the date the application
is submitted to submit all information, take and pass the SPEX. If the SPEX scores are not submitted and
received by the board within this 1 year period the applicant will have to start the application process
again and pay all required fees again.
I, understand in order to qualify for a certificate of qualification (COQ) to practice medicine in Alabama
I will have to take and pass the SPEX and I wish to continue with the application.
Affidavit and Release:
I, [] certify after being duly sworn, that all of the information supplied in the submitted application is true
and correct to the best of my knowledge, that the photograph submitted is a true likeness of myself and
was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue
statement or representation made in this application may result in the revocation of my license to practice
medicine and criminal prosecution to the fullest extent of the law.
Chapter 3 - Appendix A Medical Examiners
Supp. 6/30/19 A-12
I further authorize the release of this application and any information submitted with it or information
collected by the Alabama Board of Medical Examiners in connection with this application, including
derogatory information, to any person or organization having a legitimate need for the information and
release the Alabama Board of Medical Examiners from all liability for the release of this information. I
further authorize the release of information, including derogatory information, which may be in the
possession of other individuals or organizations to the Alabama Board of Medical Examiners and release
this person or any organization from any liability for the release of information.
_____________________________________
Applicant’s signature
Date: ____________________
County of ____________________________________________
State of ___________________________
SWORN to and subscribed before me this _____ day of
___________________________, _______
________________________________
Notary Public Signature
My Commission Expires: ______
Under Alabama law, this document is a public record and will be provided upon request.
The Alabama Board of Medical Examiners will enforce the Board’s rules and options for the
issuance of Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an
application.
Print affidavit and release, sign in presence of Notary Public, attach color picture if not uploaded, and
return original to the Alabama Board of Medical Examiners.
Attach Photograph If one was not uploaded
Medical Examiners Chapter 3/Appendix A
Supp. 6/30/19 A-13
Author: Alabama Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §34-24-70.
History: Filed November 9, 1982. Repealed and new rule adopted
in lieu thereof: Filed November 25, 1985. Amended: Filed
May 22, 1989. Repealed and Replaced: Filed December 17, 1997;
effective January 21, 1998. Amended: Filed July 26, 1999;
effective August 30, 1999. Amended: Filed August 18, 2006;
effective September 22, 2006. Amended: Filed December 13, 2007;
effective January 17, 2008. Amended: Filed October 22, 2009;
effective November 26, 2009. Amended: Filed May 16, 2013;
effective June 20, 2013. Amended: Filed July 22, 2013;
effective August 26, 2013. Amended: Filed March 20, 2014;
effective April 24, 2014. Repealed and New Rule: Filed
February 27, 2018; effective April 14, 2018. Amended: Filed
August 22, 2018; effective October 6, 2018.
Chapter 3 - Appendix B Medical Examiners
Supp. 6/30/19 A-14
ALABAMA STATE BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 – APPENDIX B
APPLICATION FOR A LIMITED CERTIFICATE OF QUALIFICATION
Medical Examiners Chapter 3/Appendix B
Supp. 6/30/19 A-17
Authors: Alabama Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73,
34-24-75
History: Amended: Filed July 26, 1999; effective
August 30, 1999. Amended: Filed February 17, 2012; effective
March 23, 2012. Amended: Filed July 22, 2013; effective
August 26, 2013. Amended: Filed March 20, 2014; effective
April 24, 2014. Repealed and New Rule: Filed February 27, 2018;
effective April 14, 2018. Amended: Filed February 20, 2019;
effective April 7, 2019.
Ed. Note: Appendix B, Application for Certificate to Practice
Medicine through Examination, was repealed and Appendix C was
renamed Appendix B per certification filed February 27, 2018;
effective April 14, 2018.
Medical Examiners Chapter 3/Appendix C
Supp. 12/31/18 A-18
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 - APPENDIX C
Alabama Board of Medical Examiners
PO Box 946
Montgomery AL 36101
848 Washington Avenue – 36104
(334) 242-4116
Application for a Certificate of Qualification under the
Retired Senior Volunteer Physician Program (RSVP)
Application for a Certificate of Qualification under the Retired Senior Volunteer Physician Program (RSVP)
Under Alabama law, this document is a public record and will be provided upon request.
To the Alabama Board of Medical Examiners: I hereby make application for a limited certificate to practice medicine in the state of Alabama under the RSVP, and submit the following statement concerning my age, moral character, preliminary and medical education and practice:
Type in the following: Name in Full Social Security Number* *(Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued)
Place of Birth Country of Birth City of Birth State/Providence of Birth Gender/Sex (at birth) Date of Birth
Contact Information The address and contact methods provided should be how the Board or Commission can contact the license applicant directly. Please DO NOT provide contact information for office managers, assistances, or license assistant companies. Address
Contact Methods Email Address Home Telephone Number Work Telephone Number
Chapter 3/Appendix C Medical Examiners
Supp. 12/31/18 A-19
Answer yes or no (if any following answers are in the affirmative, please explain in detail and provide the complete name and address of any psychiatrist/psychologist, state board, hospital, etc.):
1. Have you ever been convicted of a felony? 2. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the
practice of medicine? 3. Have you ever been convicted of any violation of a state or federal law relating to controlled
substances? 4. Have you ever been denied a state or federal controlled substance certificate? 5. Has your certificate of qualification or license to practice medicine in any state been
suspended, revoked, restricted, curtailed, or voluntarily surrendered under threat of suspension or revocation?
6. Have your staff privileges at any hospital or health care facility been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?
7. Have you ever been denied a certificate of qualification or a license to practice medicine in any state or has your application for a certificate of qualification or license to practice medicine been withdrawn under threat of denial?
8. Have you ever had a judgment rendered against you, or action settled relating to performance of your professional service?
9. To your knowledge, are you the subject of an investigation by any licensing board/agency as of the date of this application?
10. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceeding or investigation; any inquiry or other proceeding; or any proposed termination by an educational institution; employer; government agency; professional organization; or licensing authority?
11. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?
12. Are you currently* engaged in the excessive use of alcohol, controlled substances, or the use of illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues or mental health issues? (If you are an anonymous participant in the Alabama Physician Health Program and are in compliance with your contract, you may answer “No” to this question, such answer for this purpose will not be deemed upon certification as providing false information to the Alabama Board of Medical Examiners or the Medical Licensure Commission of Alabama).
You answered Yes, a description is required.
*The term “currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it means recently enough so that the condition referred to may have an ongoing impact on one’s functioning as a physician within the past two years.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other health care providers do. The Board expects its licensees to address their health concerns and ensure patient safety. Options include anonymously self-referring to the Alabama Physician Health Program (334-954-2596), a physician advocacy organization dedicated to improving the health and wellness of medical professionals in a confidential manner. The failure to
Medical Examiners Chapter 3/Appendix C
Supp. 12/31/18 A-20
adequately address a health condition, where the licensee is unable to practice medicine with reasonable skill and safety to patients, can result in the Board taking action against the license to practice medicine.
_______ Please initial certifying that you understand and acknowledge your duty as a licensee to address any such condition as stated above.
13. Within the past five years, have you been convicted of driving under the influence (DUI) or have you been charged with DUI and been convicted of a lesser offense such as reckless driving?
14. Has your medical training or medical practice been interrupted or suspended for a period longer than 60 days for any reason other than a vacation?
Education Information When entering dates attended in the education sections if you don’t know the exact date use the first date of the month. (Example: you attended from August 1990 – July 1994, Enter 08/01/1990 – 07/01/1994) Pre-Medical education
List all schools attended, undergraduate work other than medical school, dates, attended, and degree conferred. School Name State Date End Date Degree Received Medical education
List all medical Schools attended, dates, and complete addresses of institutions. Do Not list post-graduate medical education training.
Medical School Name
Start Date
End Date
Street Address
Suite
City
State
Zip
Country Post-graduate medical education training
List all post-graduate medical education training since graduation from medical school, dates, and complete address of institutions. DO NOT list practice experience.
Chapter 3/Appendix C Medical Examiners
Supp. 12/31/18 A-21
Facility Name
Start Date
End Date
Street Address
Suite
City
State
Zip
Country
Certification: 1. I hereby certify that I am now or was licensed to practice medicine in the states of [list
states], that my license to practice medicine in each of the states indicated is now or was on the date of expiration unrestricted and in good standing and that there are no currently pending disciplinary actions or investigations concerning my license in any of the states listed above. I further certify that my license to practice medicine in the states listed above has never been revoked, suspended, placed on probation, or otherwise subject to disciplinary action and that I have not had my hospital medical staff privileges revoked, suspended, curtailed, limited, or surrendered while under investigation.
2. I certify that I am fully retired from the active practice of medicine; however, I wish to volunteer my services as a physician in a free medical clinic located in [city], Alabama, and it is my expectation that I will provide not less than 100 hours of voluntary services for the calendar year [year].
3. I understand and acknowledge that issuance of a certificate of qualification and license to practice medicine under the Retired Senior Volunteer Physician Program requires that I comply with the continuing medical education requirement for physicians as specified in Chapter 14 of the rules of the Alabama Board of Medical Examiners.
Affidavit and Release: I, [name prints here], certify after being duly sworn, that all of the information supplied in the submitted application is true and correct to the best of my knowledge, that the photograph submitted is a true likeness of myself and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this
application may result in the revocation of my license to practice medicine and criminal prosecution to the fullest extent of the law. I further authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information and release the Alabama Board of Medical Examiners from all liability for the release of this information. I further authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners and release this person or any organization from any liability for the release of information.
Medical Examiners Chapter 3/Appendix C
Supp. 12/31/18 A-22
Applicant’s signature
Date: ____________________ County of ________________________________________
State of ___________________________
SWORN to and subscribed before me this _____ day of ______________________, _______
________________________________ Notary Public Signature
My Commission Expires:____________
Under Alabama law, this document is a public record and will be provided upon request.
The Alabama Board of Medical Examiners will enforce the Board’s rules and options for
the issuance of Non-Disciplinary Citation and Administrative Charge when an applicant
falsifies an application. Print affidavit and release, sign before Notary Public, attach color picture if not uploaded, and return original to the Alabama Board of Medical Examiners.
Attach Photograph If one was not uploaded
Chapter 3/Appendix C Medical Examiners
Supp. 12/31/18 A-23
Declaration of citizenship: ALABAMA BOARD OF MEDICAL EXAMINERS DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt “qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive covered state or local public benefits. With certain exceptions, Ala. Code §§ 31-13-1, et. seq., prohibits aliens unlawfully present in the U.S. from receiving state or local benefits. Every U.S. Citizen applying for a state or local public benefit must sign a declaration of Citizenship, and the lawful presence of an alien in the U.S. must be verified by the Federal Government. Ala. Code §§ 31-13-1, et. seq., also requires every individual applying for a permit or license to demonstrate his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate his/her lawful presence in the United States. Directions: This form must be completed and submitted by individuals applying for licenses or permits. SECTION 1 --- APPLICANT INFORMATION Name: Date of birth: MD / DO / PA License Number (if applicable): SECTION II --- U.S. CITIZENSHIP OR NATIONAL STATUS Are you a citizen or national of the United States (choose one) Yes No If you answered YES: (1) Provide an original (only in person at agency office) or legible copy of document from attached List A or other document that demonstrates U.S. citizenship or nationality and (2) Complete Section IV. If you answered No: Complete Sections III and IV. Name of document provided: __________________________________________________________________ SECTION III – ALIEN STATUS Are you an alien lawfully present in the United States? Yes No If you answered Yes: (1) Provide an original (only in person at agency office) or legible copy of the front and back (if any) of a document from attached List B or other document that demonstrates lawful presence in the United States. (2) Complete Section IV. Information from the documentation provided will be used to verify lawful presence through the United States Government. If you answered No: Complete Section IV. Name of document provided: _________________________________________________________________. SECTION IV -- DECLARATION I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided are true and correct to the best of my knowledge. _________________________________________________ _______________ APPLICANT’S SIGNATURE DATE
Medical Examiners Chapter 3/Appendix C
Supp. 12/31/18 A-24
LIST A DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP (1) The applicant's driver's license or nondriver's identification card issued by the division of motor vehicles or the equivalent governmental agency of another state within the United States if the agency indicates on the applicant's driver's license or nondriver's identification card that the person has provided satisfactory proof of United States citizenship. (2) The applicant's birth certificate that satisfactorily verifies United States citizenship. (3) Pertinent pages of the applicant's United States valid or expired passport identifying the applicant and the applicant's passport number. (4) The applicant's United States naturalization documents or the number of the certificate of naturalization. (5) Other documents or methods or proof of United States citizenship issued by the federal government pursuant to the Immigration and Nationality Act of 1952, and amendments thereto. (6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number. (7) The applicant’s consular report of birth abroad of a citizen of the United States of America. (8) The applicant’s certificate of citizenship issued by the United States Citizenship and Immigration Services. (9) The applicant’s certification of report of birth issued by the United States Department of State. (10) The applicant’s American Indian card, with KIC classification, issued by the United States Department of Homeland Security. (11) The applicant’s final adoption decree showing the applicant’s name and United States birthplace. (12) The applicant's official United States military record of service showing the applicant's place of birth in the United States. (13) An extract from a United States hospital record of birth created at the time of the applicant's birth indicating the applicant's place of birth in the United States. Ala. Act #2011-535, Section 30(c) and Section 29(k). LIST B DOCUMENTS INDICATING STATUS OF QUALIFIED ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED INTO U.S. FOR LESS THAN ONE YEAR The documents listed below that are registration documents are indicated with an asterisk (“*”). a. “Qualified Aliens” Evidence of “Qualified Alien” status includes the following: Alien Lawfully Admitted for Permanent Residence Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94. Asylee * Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA; * Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”; * Form I-766 (Employment Authorization Document) annotated “A5”; Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or Order of an immigration judge granting asylum. Refugee * Form I-94 annnotated with stamp showing admission under § 207 of the INA; * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or * Form I-766 (Employment Authorization Document) annotated “A3” Alien Paroled Into the U.S. for at Least One Year
Chapter 3/Appendix C Medical Examiners
Supp. 12/31/18 A-25
* Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one year requirement.) Alien Whose Deportation or Removal Was Withheld * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10); * Form I-766 (Employment Authorization Document) annotated “A10”; or Order from an immigration judge showing deportation withheld under §243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA. Alien Granted Conditional Entry * Form I-94 with stamp showing admission under §203(a)(7) of the INA; * Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or * Form I-766 (Employment Authorization Document) annotated “A3.” Cuban / Haitian Entrant * Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6; Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code CU6 or CU7; or Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA. Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty U.S. Citizenship and Immigration Service petition and supporting documentation
Medical Examiners Chapter 3/Appendix C
Supp. 12/31/18 A-26
(Letterhead)
CERTIFICATION OF FREE CLINIC
DATE:_____________________
TO: State Board of Medical Examiners
This is to certify that ______________________________, M.D./D.O.
has agreed to perform no fewer than 100 hours of voluntary
professional services annually at the ,
(Clinic Name)
located at ___________________, Alabama, which is an established free
medical clinic operating under the provisions of Ala. Code §6-5-660
and provides outpatient medical care to patients unable to pay for it.
Clinic or Facility Administrator
Address
Telephone
Facsimile
Chapter 3/Appendix C Medical Examiners
Supp. 12/31/18 A-27
Author: Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73,
34-24-75.
Repealed: Filed December 17, 1997; effective January 21, 1998.
New Appendix: Filed January 21, 2005; effective
February 25, 2005. Amended: Filed February 17, 2012; effective
March 23, 2012. Amended: Filed July 22, 2013; effective
August 26, 2013. Amended: Filed March 20, 2014; effective
April 24, 2014. Amended: Filed Octobr 20, 2016; effective
December 4, 2014. Repealed and New Rule: Filed
February 27, 2018; effective April 14, 2018. Amended: Filed
November 1, 2018; effective December 16, 2018.
Ed. Note: Appendix C was renamed Appendix B, and Appendix E was
renamed Appendix C per certification filed February 27, 2018;
effective April 14, 2018.
Medical Examiners Chapter 3/Appendix D
Supp. 12/31/18 A-28
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 - APPENDIX D
Under Alabama law, this document is a public record and will be provided upon request
Alabama Board of Medical Examiners
Retired Senior Volunteer Program Certificate of Qualification Renewal Application
Ala. Code § 34-24-75 requires that all physicians holding limited licenses under retired the senior
volunteer program apply to the Board of Medical Examiners for renewal of the certificate of qualification
prior to renewal of the license. In accordance with this section, you are required to accurately complete
this application. Once the application has been completed, please return it to the institution to obtain the
certification of the qualified clinic or nonprofit organization.
Full name
Name of qualified clinic or nonprofit organization
License number
Date issued
Please answer yes or no to the following questions (if any below answers are in the affirmative, please
explain in detail and provide the complete name and address of any psychiatrist/psychologist, state board,
hospital, etc.)
1. Do you limit your practice to the confines of the institution?
2. Have you ever been convicted of a felony?
3. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the
practice of medicine?
4. Have you ever been convicted of any violation of a state or federal law relating to controlled
substances?
5. Have you ever been denied a state or federal controlled substance certificate?
6. Has your certificate of qualification or license to practice medicine in any state ever been
suspended, revoked, restricted, curtailed or voluntarily surrendered under threat of suspension or
revocation?
7. Have your staff privileges at any hospital or health care facility ever been revoked, suspended,
curtailed, limited or placed under conditions restricting your practice?
8. Have you ever been denied a certificate of qualification or a license to practice medicine in any
state or has your application for a certificate of qualification or license to practice medicine been
withdrawn under threat of denial?
9. Have you ever had a judgment rendered against you or action settled relating to the performance
of your professional service?
10. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or
the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense,
mitigation, or explanation for your actions in the course of any administrative or judicial
proceeding or investigation; any inquiry or other proceeding; or any proposed termination by an
educational institution, employer, government agency, professional organization or licensing
authority?
Chapter 3 - Appendix D Medical Examiners
Supp. 12/31/18 A-29
11. Have you ever been diagnosed as having or have you ever been treated for pedophilia,
exhibitionism, or voyeurism?
12. Are you currently* engaged in the excessive use of alcohol, controlled substances, or the use of
illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues
or mental health issues? (If you are an anonymous participant in the Alabama Physician Health
Program and are in compliance with your contract, you may answer “No” to this question, such
answer for this purpose will not be deemed upon certification as providing false information to
the Alabama Board of Medical Examiners or the Medical Licensure Commission of Alabama).
If you answer “Yes,” then a description is required.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those
involving mental health and substance use disorders, just as their patients and other health care
providers do. The Board expects its licensees to address their health concerns and ensure patient
safety. Options include anonymously self-referring to the Alabama Physician Health Program
(334-954-2596), a physician advocacy organization dedicated to improving the health and
wellness of medical professionals in a confidential manner. The failure to adequately address a
health condition, where the licensee is unable to practice medicine with reasonable skill and
safety to patients, can result in the Board taking action against the license to practice medicine.
_______ Please initial certifying that you understand and acknowledge your duty as a licensee to
address any such condition as stated above.
*The term “currently” does not mean on the day of, or even in the weeks or months preceding the
completion of this application. Rather, it means recently enough so that the condition referred to
may have an ongoing impact on one’s functioning as a physician within the past two years.
13. Have you been within the past five years convicted of driving under the influence (DUI) or have
you been charged with DUI and been convicted of a lesser offense such as reckless driving?
14. Has your medical training or medical practice been interrupted or suspended for a period longer
than 60 days for any reason other than a vacation?
I hereby certify that the foregoing is true and correct to the best of my knowledge.
Date
Applicant’s signature
I hereby certify that the information contained in this renewal application is true to the best of my
knowledge.
Date
Type or print Clinic or Facility Administrator name
Clinic/Facility Administrator signature
Medical Examiners Chapter 3/Appendix D
Supp. 12/31/18 A-30
Author: Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73,
34-24-75.
Repealed: Filed December 17, 1997; effective January 21, 1998.
New: Filed December 15, 2005; effective January 19, 2006.
Amended: Filed February 17, 2012; effective March 23, 2012.
Amended: Filed March 20, 2014; effective April 24, 2014.
Repealed and New Rule: Filed February 27, 2018; effective
April 14, 2018.
Ed. Note: Appendix D, Certification of Established Free Medical
Clinic, was repealed and Appendix F was renamed Appendix D per
certification filed February 27, 2018; effective April 14, 2018.
Chapter 3/Appendix E Medical Examiners
Supp. 6/30/19 A-31
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 - APPENDIX E
Limited Certificate of Qualification Renewal Application
Chapter 3/Appendix E Medical Examiners
Supp. 6/30/19 A-33
Author: Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-53.1, 34-24-70.
History: Amended: Filed October 21, 2010; effective
November 25, 2010. Amended: Filed February 17, 2012; effective
March 23, 2012. Amended: Filed March 20, 2014; effective
April 24, 2014. Repealed and New Rule: Filed August 17, 2017;
effective October 1, 2017. Repealed and New Rule: Filed
February 27, 2018; effective April 14, 2018. Amended: Filed
February 20, 2019; effective April 7, 2019.
Ed. Note: Appendix E was renamed Appendix C, and Appendix G was
renamed Appendix E per certification filed February 27, 2018;
effective April 14, 2018.
Chapter 3/Appendix F Medical Examiners
Supp. 12/31/18 A-34
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 3 - APPENDIX F
Alabama Board of Medical Examiners
PO Box 946
Montgomery AL 36101
848 Washington Avenue – 36104
(334) 242-4116
Application for Reinstatement of Certificate of Qualification
Name
Address
Email address
Initial license number
Issue Date
Telephone (H)
Telephone (W)
Date of revocation/suspension/surrender of certificate of qualification
Reasons for revocation/suspension/voluntary surrender of certificate or license (please give detailed
reasons)
Answer yes or no (if the answer to any of these questions is YES, please explain in detail):
1. Have you ever been convicted of a felony?
2. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the
practice of medicine?
3. Have you ever been denied a state or federal controlled substance certificate?
4. Has your certificate of qualification or license to practice medicine in any state been suspended,
revoked, restricted, curtailed, or voluntarily surrendered under threat of suspension or
revocation?
5. Have your staff privileges at any hospital or health care facility been revoked, suspended,
curtailed, limited, or placed under conditions restricting your practice?
6. Have you ever been denied a certificate of qualification or a license to practice medicine in any
state or has your application for a certificate of qualification or license to practice medicine been
withdrawn under threat of denial?
7. Have you ever had a judgment rendered against you, or action settled relating to performance of
your professional service?
8. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or
the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense,
mitigation, or explanation for your actions in the course of any administrative or judicial
proceeding or investigation; any inquiry or other proceeding; or any proposed termination by an
educational institution; employer; government agency; professional organization; or licensing
authority?
Medical Examiners Chapter 3 - Appendix F
Supp. 12/31/18 A-35
9. Have you ever been diagnosed as having or have you ever been treated for pedophilia,
exhibitionism, or voyeurism?
10. Are you currently* engaged in the excessive use of alcohol, controlled substances, or the use of
illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues
or mental health issues? (If you are an anonymous participant in the Alabama Physician Health
Program and are in compliance with your contract, you may answer “No” to this question, such
answer for this purpose will not be deemed upon certification as providing false information to
the Alabama Board of Medical Examiners or the Medical Licensure Commission of Alabama).
If you answer “Yes,” then a description is required.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those
involving mental health and substance use disorders, just as their patients and other health care
providers do. The Board expects its licensees to address their health concerns and ensure patient
safety. Options include anonymously self-referring to the Alabama Physician Health Program
(334-954-2596), a physician advocacy organization dedicated to improving the health and
wellness of medical professionals in a confidential manner. The failure to adequately address a
health condition, where the licensee is unable to practice medicine with reasonable skill and
safety to patients, can result in the Board taking action against the license to practice medicine.
_______ Please initial certifying that you understand and acknowledge your duty as a licensee to
address any such condition as stated above.
*The term “currently” does not mean on the day of, or even in the weeks or months preceding the
completion of this application. Rather, it means recently enough so that the condition referred to
may have an ongoing impact on one’s functioning as a physician within the past two years.
11. Within the past five years, have you been convicted of driving under the influence (DUI) or have
you been charged with DUI and been convicted of a lesser offense such as reckless driving?
12. Has your medical training or medical practice been interrupted or suspended for a period longer
than 60 days for any reason other than a vacation?
Please list all states in which you have applied for licensure
I hereby certify that the information contained herein is true and accurate to the best of my ability.
Applicant’s signature
Sworn to and subscribed before me this ___ day of ____________, 20___.
Notary Public
My commission expires: _____
Under Alabama law, this document is a public record and will be provided upon request.
Print application, sign in presence of Notary Public, and return original to the Alabama Board of Medical
Examiners.
I hereby authorize the release of any information concerning me in your files, favorable or otherwise, to
the Alabama Board of Medical Examiners. A copy of this authorization shall be as valid as the original.
Applicant’s signature
Chapter 3/Appendix F Medical Examiners
Supp. 12/31/18 A-36
Author: Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73,
34-24-75.
History: Amended: Filed February 17, 2012; effective
March 23, 2012. Amended: Filed March 20, 2014; effective
April 24, 2014. Repealed and New Rule: Filed February 27, 2018;
effective April 14, 2018.
Ed. Note: Appendix F was renamed Appendix D, and Appendix H was
renamed Appendix F per certification filed February 27, 2018;
effective April 14, 2018.
Medical Examiners Chapter 4 - Appendix A
Supp. 12/31/18 A-37
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 4 - APPENDIX A
ALABAMA BOARD OF MEDICAL EXAMINERS
P. O. Box 946 – Montgomery, Alabama 36101 • 848 Washington Avenue – 36104
Application for Controlled Substances Registration Certificate WARNING: SECTION 20-2-54. CODE OF ALABAMA 1975 (AS AMENDED) STATES THAT A REGISTRATION MAY BE
SUSPENDED OR REVOKED BY THE BOARD UPON A FINDING THAT THE REGISTRANT HAS FURNISHED FALSE OR
FRAUDULENT MATERIAL INFORMATION IN AN APPLICATION.
-APPLICATION-
CONTROLLED SUBSTANCES
REGISTRATION CERTIFICATE
Return Completed Application To:
ALABAMA STATE BOARD OF
MEDICAL EXAMINERS
P.O. Box 946 • Montgomery, Alabama 36101
(334) 242-4116
Under Alabama law, this document is a public record and will be
provided upon request
All applicants must answer the following questions. If the answer
to question A, B, C, D, or E is yes, the applicant must provide a
complete explanation detailing all facts and circumstances.
A. Has your privilege for dispensing or prescribing controlled substances ever been suspended, restricted, voluntarily
surrendered while under investigation or revoked in any state?
B. Have you ever been convicted of any state or federal crime
relating to any
controlled substance?
C. Has your Federal DEA registration ever been suspended,
restricted, revoked or voluntarily surrendered while under
investigation
D. Have your staff privileges at any hospitals ever been
suspended, restricted or revoked for any reason related to the
prescribing or dispensing of controlled substances?
E. Are you currently* engaged in the excessive use of alcohol,
controlled substances, or the use of illegal drugs, or received
any therapy or treatment for alcohol or drug use, sexual boundary
issues or mental health issues? (If you are an anonymous
Chapter 4 - Appendix A Medical Examiners
Supp. 12/31/18 A-38
participant in the Alabama Physician Health Program and are in
compliance with your contract, you may answer "No" to this
question, such answer for this purpose will not be deemed upon
certification as providing false information to the Alabama Board
of Medical Examiners or the Medical Licensure Commission of
Alabama)
*The term “currently” does not mean on the day of, or even in the weeks or months preceding the
completion of this application. Rather, it means recently enough so that the condition referred to
may have an ongoing impact on one’s functioning as a physician within the last two years.
IMPORTANT: The Board recognizes that licensees encounter health
conditions, including those involving mental health and substance
use disorders, just as their patients and other health care
providers do. The Board expects its licensees to address their
health concerns and ensure patient safety. Options include
anonymously self-referring to the Alabama Physician Health
Program (334-954-2596), a physician advocacy organization
dedicated to improving the health and wellness of medical
professionals in a confidential manner. The failure to
adequately address a health condition, where the licensee is
unable to practice medicine with reasonable skill and safety to
patients, can result in the Board taking action against the
license to practice medicine.
Please initial certifying that you understand and acknowledge
your duty as a licensee to address any such condition as stated
above.
THE ANNUAL FEE FOR THIS CERTIFICATE IS $150.00.
I swear (affirm) that the information set forth in this
application for Alabama controlled substances registration
certificate is true and correct to the best of my knowledge,
information and belief.
I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief. Knowingly providing false information to the Alabama Board of Medical Examiners or Medical Licensure Commission of Alabama could result in disciplinary action.
Medical Examiners Chapter 4 - Appendix B
Supp. 12/31/18 A-39
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 4 - APPENDIX B
CONTROLLED SUBSTAMCES CERTIFICATE REGISTRATIOM RENEWAL
Renewal - 20XX
Alabama Controlled Substances Certificate Registration Renewal
Deadline: December 31, 20XX
WARNING: SECTION 20-2-54, CODE OF ALABAMA 1975 (AS AMENDED) STATES THAT
A REGISTRATION MAY BE SUSPENDED OR REVOKED BY THE BOARD UPON A
FINDING THAT THE REGISTRANT HAS FURNISHED FALSE OR FRAUDULENT
MATERIAL INFORMATION IN ANY APPLICATION.
Under Alabama law, this document is a public record and will be provided upon request it will be
provided in its entirety.
Please answer yes or no. If any answers are YES, please include a detailed explanation.
A. Has your privilege for dispensing or prescribing controlled substances ever been suspended,
restricted, revoked, voluntarily surrendered while under investigation or disciplined in any manner in
any state?
B. Have you ever been convicted of any state or federal crime relating to any controlled substance?
C. Has your Federal DEA registration ever been suspended, restricted, revoked or voluntarily
surrendered while under investigation?
D. Have your staff privileges at any hospital ever been suspended, restricted, revoked, or disciplined
in any manner for any reason related to the prescribing or dispensing of controlled substances?
E. Since your last renewal, have you engaged in the excessive use of alcohol, controlled
substances, or the use of illegal drugs, or received any therapy or treatment for alcohol or drug
use, sexual boundary issues or mental health issues? (If you are an anonymous participant in the
Alabama Physician Health Program and are in compliance with your contract, you may answer
"No" to this question, such answer for this purpose will not be deemed upon certification as
providing false information to the Alabama Board of Medical Examiners or the Medical
Licensure Commission of Alabama)
If you answer "Yes", then a description is required.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other health care providers do. The Board expects its licensees to address their health concerns and ensure patient safety. Options include anonymously self-referring to the Alabama Physician Health Program (334-954-2596), a physician advocacy organization dedicated to improving the health and wellness of medical professionals in a confidential manner. The failure to adequately address a health condition, where the licensee is unable to practice medicine with reasonable skill and safety to patients, can result in the Board taking action against the license to practice medicine.
Chapter 4 - Appendix B Medical Examiners
Supp. 12/31/18 A-40
__________Please initial certifying that you understand and acknowledge your duty as a licensee to address any such condition as stated above.
F. Do you have a current registration to access the Alabama Prescription Drug monitoring database
Program (PDMP)? Yes No
G. Do you dispense controlled substances, other than pharmaceutical samples, from any practice
location? If yes, I confirm my Registration Form is on file with the ALBME. Yes No
H. Do you have a current registration issued by the U. S. Drug Enforcement Administration? Yes
No
Please provide your Primary DEA number and expiration date.
DEA Number
DEA Expiration Date
NOTICE: A current registration to access the Prescription Drug Monitoring Database and a
current registration issued by the U.S. Drug Enforcement Administration are required before
renewing an Alabama Controlled Substances Certificate. For further information concerning
DEA registration, contact DEA, (800) 882-9539. For further information concerning the
prescription database, contact the Alabama Dept. of Public Health, (855-925-4767).
List any additional DEA numbers and addresses for other locations
DEA Number
DEA Expiration Date
Address Location for DEA Number
I understand and agree that by typing my name, I am providing an electronic signature that has
the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest
that the foregoing information has been provided by me and is true and correct to the best of my
knowledge, information and belief.
Knowingly providing false information to the Alabama Board of Medical Examiners could result
in disciplinary action.
Medical Examiners Chapter 4 - Appendix C
Supp. 12/31/18 A-41
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 4 - APPENDIX C
Chapter 4 - Appendix C Medical Examiners
Supp. 12/31/18 A-42
Author: Board of Medical Examiners
Statutory Authority:
History: Amended (Appendices A and B): Filed October 21, 2005;
effective November 25, 2005. Amended (Appendix A): Filed
November 13, 2007; effective December 18, 2007. Amended: Filed
November 14, 2013; effective December 19, 2013. Repealed and New
Rule: Filed July 20, 2017; effective September 3, 2017. New
Rule (Appendix C only): Filed December 14, 2017; effective
January 28, 2018. Amended (Appendix A and B only): Filed
February 27, 2018; effective April 14, 2018. Amended (Appendix A
only): Filed August 22, 2018; effective October 6, 2018.
Medical Examiners Chapter 7/Appendix A
Supp. 12/31/18 A-43
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX A
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946/Montgomery, AL 36101-0946/(334) 242-4116
APPLICATION FOR REGISTRATION OF PHYSICIAN ASSISTANT
PHYSICIAN:
Supervising Physician Name in Full
AL Medical License Number
Medical Specialty
Board Certified
Board Eligible
Practice Address
County
Street
Apt/Suite
State
Zip
Telephone Number
Is the physician assistant for whom registration is sought employed by you or by your group, partnership
or professional corporation?
You answered No, a Supplemental Certificate must be submitted.
PHYSICIAN ASSISTANT
Physician Assistant Name in Full
AL P. A. License Number
Covering Physicians
Would you like to add covering physicians to this registration agreement?
P. A./Physician Supervisory Agreement Core Duties and Scope Of Practice
1. The P. A. may work in any setting consistent with the supervising physician’s scope of practice and
are customary to the Supervising Physician’s scope of practice and are customary to the practice of
the Physician. The P. A. scope of practice shall be defined as those functions and procedures for
which the P. A. is qualified by formal education, clinical training, area of certification and
experience.
2. The following skills and functions are the core duties which may be performed by the P. A.
a. Arrange inpatient hospital admissions, transfers, and discharges in accordance with established
guidelines/standards developed within the practice of the supervising physician and P. A.; perform
rounds and record appropriate patient progress notes; compile detailed narrative and case summaries;
complete forms pertinent to patients’ medical records.
Chapter 7/Appendix A Medical Examiners
Supp. 12/31/18 A-44
b. Perform detailed and accurate health histories, review patient records, develop comprehensive
medical status reports, and order laboratory, radiological, therapeutic and diagnostic studies or
treatment appropriate for the complaint, age, race, sex and physical condition of the patient.
c. Perform comprehensive physical exams and assessments. Formulate medical diagnoses, including
the interpretation and evaluation of patient data to determine patient management and treatment,
including the institution of therapy and ordering of medical devices or referral of patients to
appropriate care facilities and/or agencies and other resources of the community or other physicians.
d. Prescribe legend drugs authorized by the supervising physician and included on the formulary
approved by the guidelines established by the Alabama Board of Medical Examiners for P.A.s.
e. Institute emergency measures and emergency treatment or appropriate stabilization measures in
situations such as cardiac arrest, shock, hemorrhage, convulsions, poisoning and emergency obstetric
delivery where indicated.
f. Provide instructions, education and guidance regarding healthcare and healthcare promotion to
patients, family and caregivers.
g. Skills and functions that are taught in usual and standard PA academic education and do not require
additional training or course documentation. The supervising physician and PA may document and
validate that the PA has received education, training and competency to perform the core duty or
skill.
h. The Board of Medical Examiners recognizes the following as examples of usual and customary core
duties and skills that a Physician Assistant can perform, including, but not limited to, the following:
(1) Perform the following example procedures/skills:
(a) Surgical Assisting
(b) Wound debridement, suturing and care of superficial wounds.
(c) Skin biopsies (facial biopsies are to be requested).
(d) Insert and removal of drains (excluding paracentesis, thoracentesis, thoracostomy tube insertion,
ventriculostomy insertion, and placement of any percutaneous drain into a body cavity).
(e) Suturing-single layer closure of the face.
(f) Vein or artery cut-down for access.
(g) Vein harvesting.
(h) Surgical wound closure-may close the outermost layer of the fascia, subcutaneous tissue, dermis
and epidermis on extremities; over thoracic or abdominal cavities approval to close subcutaneous,
dermis and epidermis only.
(i) Removal of superficial foreign body of the eyeball.
(j) Incision and drainage of superficial skin infections or abscesses.
(k) PICC line placement
(l) Tracheostomy tube change
(m) Thoracostomy tube removal
(n) Enteric tube exchange
(o) Groshong catheter removal
(p) Infusaport (portacath) removal
(q) Post pyloric feeding tube placement
(r) Removal of pacing wires
(s) Intubation
(t) Escharotomy
(u) Cardiac stress test monitoring.
i. Signature Authority Delegation Standard Delegation, which includes:
(1) Certification of patient disability for disabled parking tags/placards.
(2) Physicals for bus drivers using State of Alabama forms.
(3) Authorizations for durable medical equipment.
Medical Examiners Chapter 7/Appendix A
Supp. 12/31/18 A-45
(4) Authorizations for diabetic testing supplies.
(5) Authorization for diabetic shoes.
(6) Within the State Medicaid system, forms for:
(a) ordering medications, nutritional supplements, infant formulas,
(b) referrals to medical specialist,
(c) referrals for home health services,
(d) referrals for physical or occupation therapy.
(7) Within the Department of Mental Health, forms for:
(a) physical examination,
(b) certifications in residential or inpatient dwellings.
Signature Authority Delegation Optional Delegations
Please uncheck any optional delegations NOT to approve.
Absenteeism forms for employment or school purposes, including documents associated with the
Federal Family and Medical Leave Act.
Home health care recertification orders.
Physicals to verify eligibility for students to participate in the Special Olympics.
Employment and pre-employment physicals for Transportation Security Agency (TSA) employees
at an airport or for governmental employees such as firefighters and law enforcement officers.
Adoptive parent applications.
College or trade school physicals.
Boy Scout or Girl Scout physicals or physical required by similar organizations.
Forms excusing a potential jury member due to an illness.
Death certificates.
Forms for ambulance transport.
Forms for donor breast milk.
Required documentation allowing a diabetic to renew or obtain a driver’s license.
j. For additional skills requested outside the core duties of the P. A. by the supervising physician (i.e.
diagnostic or surgical procedures requiring additional training), the supervising physician must
provide documentation of the training and / or certification which qualifies the P. A. The training for
the additional duty/skill shall have been previously approved by the Board.
Do you want to request approval to train for additional skills at this time?
See attached “Additional Skills Request Protocol” from the supervising physician.
k. Provide emergency medical services in the event of declared national emergency or natural disaster
in accordance with the requirements of Board Rules.
3. List each practice site where this Job Description will be utilized and the number of hours this P.
A. will be working weekly in each site.
Practice Site Address
Name, (Practice/Site Name)
Country
Street
Apt/Suite
City
State
Zip
County
Phone Number
4. Is there a request for the P. A. to practice in a remote site?
You answered Yes, Please complete the following information from the physican requesting
approval to utilize the PA at a remote site.
Chapter 7/Appendix A Medical Examiners
Supp. 12/31/18 A-46
Remote Site Address
Name, (Practice/Site Name)
Country
Street
Apt/Suite
City
State
Zip
County
Phone Number
Number of hours and at what frequency will the supervising physician will visit the remote site.
Number of hours the PA will spend in the remote site weekly
Number of hours both will be present together
Provide a plan describing the facilities and arrangements for appropriate communication,
consultation and review.
5. Provide a written plan for review of medical records and patient outcomes. (Example: what
percentage of charts will be reviewed, who will perform the review, and how often the review will
take place). The review should be documented and maintained at the practice location.
Who will perform the review
What percentage of charts will be reviewed
How often will the review take place
Additional Comments
6. Will this P. A. be authorized to have prescriptive privileges?
You answered Yes, comlete the Formulary which is a list of the legend drugs which are authorized
by the Physician to be prescribed by the P. A. The formulary approved under the rules of the Board
of Medical Examiners should be utilized and attached as the authorized legend drugs to be
prescribed. The medication categories chosen should reflect the needs of the supervising physician’s
medical practice.
7. Will this P. A. be authorized to have prescriptive privileges to prescribe controlled substances as
allowed under Alabama Code Section 20-2-60, et. seq.? (Prerequisites for controlled substances
prescribing by P.A.s are stated in Board Rules, Chapter 540-X-12)
If yes, the application for a Qualified Alabama Control Substance Certificate can be found at our web
site, www.albme.org.
We hereby certify under penalty of law of the State of Alabama that the foregoing information in this
Physician Assistant Job Description is correct to the best of our knowledge and belief. We certify that we
have reviewed the current rules of the Alabama Board of Medical Examiners pertaining to assistants to
physicians and understand our responsibilities. We understand that we are equally responsible for the
actions of the Assistant to the Physician.
Under Alabama law, this document is a public record and will be provided upon request
I understand and agree that by typing my name, I am providing an electronic signature that has the same
legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing
information has been provided by me and is true and correct to the best of my knowledge, information
and belief.
Knowingly providing false information to the Alabama Board of Medical Examiners or Medical
Licensure Commission of Alabama could result in disciplinary action.
Medical Examiners Chapter 7/Appendix A
Supp. 12/31/18 A-47
SUPPLEMENTAL CERTIFICATE TO APPLICATION
FOR REGISTRATION AS A PHYSICIAN ASSISTANT
To:
(Name and Address of Hospital or Corporate Employer)
The State Board of Medical Examiners has been presented with an application from
, P. A., for certification as a physician assistant to
, M.D. Information available to the Board indicates that
________________________________, M.D., is an employee of
(legal entity), and that , Physician
Assistant, is an employee of (legal entity).
To assist the Board in evaluating this application, it is requested that this questionnaire be
filled out and executed by the President, Chairman, Chief Executive Officer or Chief
Administrative Officer of the corporation or other legal entity that employs the physician and/or
the physician assistant. These questions relate directly to the supervisory relationship
contemplated by Board Rules, Chapter 540-X-7. When an additional explanation is to be
provided, please attach additional information on separate pages.
1. Is the physician whose name appears above, employed by you to engage in the full-time
practice of medicine? If the answer to this question is no, please provide the Board
with details of the employment agreement between your corporation and the physician.
2. Does the physician whose name is stated above have the unqualified authority to terminate
the employment of the physician assistant registered to him/her? If the answer to this
question is no, please set out in detail the steps required to terminate the employment of the
physician assistant and identify the officer or officers of the corporation authorized to make
that decision.
3. Does the physician whose name is stated above, have the unqualified authority to determine
the levels of compensation to be paid to the physician assistant registered to him/her?
If the answer to this question is no, please set forth in detail the manner in which the
compensation of the physician assistant is established and the identification of the officer or
officers of the corporation who are authorized to establish, increase or reduce the
compensation of the physician assistant.
4. Does the physician whose name appears above have the unqualified authority in matters
relating to patient care to enforce compliance with orders and directives issued to the
physician assistant? Please describe in detail the manner in which such orders and
directives may be enforced.
5. Is the physician assistant whose name appears above subject to the supervision, direction or
control of any officer, director, supervisor or employee of the corporation other than the
physician to whom he/she is registered? If the answer to this question is yes, please
explain in detail, identifying the individual exercising the supervision, direction or control
and the circumstances in which such supervision, direction and control would be exercised.
Chapter 7/Appendix A Medical Examiners
Supp. 12/31/18 A-48
6. In matters relating to patient care, is the physician assistant whose name appears above
subject to the immediate supervision, direction or control of any non-physician?
If yes, explain the relationship.
7. Will the physician assistant whose name appears above be expected or required to perform
any part of his/her duties at any time when the physician to whom he/she is registered is not
on duty and physically present on the premises of the hospital, clinic, or facility where the
physician’s assistant services will be rendered? If the answer to this question is
yes, please explain in detail all such circumstances.
I understand that the information submitted herein is to be used by the Board of Medical
Examiners as the basis for registration of a physician assistant and that the furnishing of false or
misleading information or the future occurrence of substantial departures from or violations of
the standards and procedures outlined in this response may be considered by the Board as
grounds for termination of the registration of the physician assistant.
The undersigned hereby certifies that the foregoing information is true and correct to the
best of my knowledge, information and belief.
Name of the Corporation Title of Officer Signing Certificate
Printed Name of the Officer Signing Certificate Signature
This form may be sent to the Board via facsimile or email (see instructions)
Medical Examiners Chapter 7/Appendix B
Supp. 12/31/18 A-49
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX B
Alabama Board of Medical Examiners
PO Box 946 / Montgomery AL 36101-0946 / (334) 242-4116
Application for Licensure of Physician Assistant
Physician Assistant’s name in full
Social Security Number*
*Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social
security number (SSN) on this application. The uses of your SSN are limited to the purpose of
administering the state child support program and intra-agency for identification purposes. If your SSN
is not provided, your application is not complete, and no license will be issued.
Place of Birth
Country of Birth
City of Birth
State/Province of Birth
Gender/Sex (at birth)
Date of Birth
Contact Information
The address and contact methods provided should be how the Board or Commission can contact the license
applicant directly. Please DO NOT provide contact information for office managers, assistants, or license
assistance companies.
Home Address
Country
Street
Apt/Suite
City
State
Zip
County
If you answer yes to any of the following questions, please provide a detailed explanation and provide the
complete address of any psychiatrist/psychologist, state board, hospital, etc., if appropriate:
1. Have you ever been convicted of a felony?
2. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the
practice of medicine?
3. Have you ever been convicted of any violation of a state or federal law relating to controlled
substances?
4. Have you ever been denied a state or federal controlled substance certificate?
5. Have you ever been denied prescription privileges for non-controlled or legend drugs by any
state or federal authority?
Chapter 7/Appendix B Medical Examiners
Supp. 12/31/18 A-50
6. Has your certification or license to practice as a physician assistant in any state been suspended,
revoked, restricted, curtailed, or voluntarily surrendered while under investigation in any state?
7. Have your staff privileges at any hospital or health care facility been revoked, suspended,
curtailed, limited, placed under conditions restricting your practice, or voluntarily surrendered
while under investigation?
8. Have you ever been denied a certification or license to practice as a physician assistant in any
state or has your application for certification or for a license to practice as a physician assistant
been withdrawn under threat of denial?
9. Have you ever had a judgment rendered against you or action settled relating to the performance
of your professional service?
10. Have you successfully completed the Physician Assistant National Certifying Examination?
If YES, upload verifying documentation from the National Commission on Certification of
Physician Assistants (NCCPA).
If NO, have you ever taken the examination?
Are you registered to take the PANCE?
If YES upload verifying documentation from the NCCPA. PANCE Test date:
11. Are you currently registered, certified to or working for any other primary supervising physician
in an another state? ie Are you presently working as a physician assistant? If so, answer yes.
If YES, provide the name and principal practice location of each primary supervising physician
to whom you are certified. In addition, state your designated working hours per week for each
physician listed.
12. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or
the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense,
mitigation, or explanation for your actions in the course of any administrative or judicial
proceeding or investigation; any inquiry or other proceeding; or any proposed termination by an
educational institution, employer, government agency, professional organization or licensing
authority?
13. Have you ever been diagnosed as having or have you ever been treated for pedophilia,
exhibitionism or voyeurism?
14. Are you currently* engaged in the excessive use of alcohol, controlled substances, or the use of
illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues
or mental health issues? (If you are an anonymous participant in the Alabama Physician Health
Program and are in compliance with your contract, you may answer "No" to this question, such
answer for this purpose will not be deemed upon certification as providing false information to the
Alabama Board of Medical Examiners)
You answered Yes, please provide a description.
*The term “currently” does not mean on the day of, or even in the weeks or months preceding the
completion of this application. Rather, it means recently enough so that the condition referred to may
have an ongoing impact on one’s functioning as an assistant to a physician within the past two years.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those
involving mental health and substance use disorders, just as their patients and other health care
providers do. The Board expects its licensees to address their health concerns and ensure patient
safety. Options include anonymously self-referring to the Alabama Physician Health Program
(334-954-2596), a physician advocacy organization dedicated to improving the health and
wellness of medical professionals in a confidential manner. The failure to adequately address a
health condition, where the licensee is unable to practice with reasonable skill and safety to
patients, can result in the Board taking action against the license to practice as a physician
assistant.
Medical Examiners Chapter 7/Appendix B
Supp. 12/31/18 A-51
Please type your initial(s) certifying that you understand and acknowledge your duty as a licensee
to address any such condition as stated above.
15. Have you been, within the past five years, convicted of driving under the influence (DUI) or have
you been charged with DUI and been convicted of a lesser offense such as reckless driving?
16. Has your medical training or medical practice been interrupted or suspended for a period longer
than 60 days for any reason other than a vacation?
Education Information
When entering dates attended in the education sections if you do not know the exact date use the first
date of the month. (Example: you attended from August 1990 – July 1994, enter 08/01/1990 –
07/01/1994)
Applicant’s Education (since graduating from high school)
Upload a copy of your diploma(s) reflecting graduation from a Physician Assistant Program
School Name
Start Date
End Date
School Address
Applicant’s Activities since graduating from high school (cover all time periods)
Place of Employment or Activity
Start Date
End Date
Address
Certification of licensure (list all states where you have been certified/registered/licensed as a
Physician Assistant). It is a requirement that each state provide directly to the Board a verification.
Copies via facsimile or email are accepted (see instructions). It is your responsibility to make the
request to each state.
State
Affidavit and Release:
I, [name], certify after being duly sworn, that all of the information supplied in the submitted application
is true and correct to the best of my knowledge, that the photograph submitted herein is a true likeness of
the assistant and was taken within sixty days prior to the date of this application. I acknowledge that any
false or untrue statement or representation made in this application may result in the revocation of any
certification / licensure granted.
I further authorize the release of this application and any information submitted with it or information
collected by the Alabama Board of Medical Examiners in connection with this application, including
derogatory information, to any person or organization having a legitimate need for the information and
release of the Alabama Board of Medical Examiners from all liability for the release of this information.
I further authorize the release of information, including derogatory information, which may be in the
possession of other individuals or organizations to the Alabama Board of Medical Examiners and release
this person or any organization from any liability for the release of information.
Chapter 7/Appendix B Medical Examiners
Supp. 12/31/18 A-52
________________________________
Physician Assistant’s Signature
Date: ____________________ County of ____________________________________________
State of ___________________________
SWORN to and subscribed before me this _____ day of
___________________________, _______
____________________________________
Notary Public Signature
My Commission Expires: ________________
Under Alabama law, this document is a public record and will
be provided upon request
The Alabama Board of Medical Examiners will enforce the Board’s rules and options for the
issuance of Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an
application.
Print affidavit and release, sign in presence of Notary Public, attach color picture if not uploaded, and
mail original to the Alabama Board of Medical Examiners.
Attach Photograph, if one was not uploaded.
Medical Examiners Chapter 7/Appendix B
Supp. 12/31/18 A-53
ALABAMA BOARD OF MEDICAL EXAMINERS
DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN
ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of
1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United
States non-citizen nationals, non-exempt “qualified aliens” (and sometimes only particular
categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States
are eligible to receive covered state or local public benefits.
With certain exceptions, Ala. Code § 31-13-1, et. seq. prohibits aliens unlawfully present in the
U.S. from receiving state or local benefits. Every U.S. Citizen applying for a state or local public
benefit must sign a declaration of Citizenship, and the lawful presence of an alien in the U.S.
must be verified by the Federal Government.
Act 2011-535 also requires every individual applying for a permit or license to demonstrate
his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate his/her lawful
presence in the United States.
Directions: This form must be completed and submitted by individuals applying for licenses or
permits.
SECTION 1 --- APPLICANT INFORMATION
NAME: (Last)(First)(M.I.)
DATE OF BIRTH:
SECTION II --- U.S. CITIZENSHIP OR NATIONAL STATUS
Are you a citizen or national of the United States (check one) Yes/No
If you answered YES: (1) Provide an original (only in person at agency office) or legible copy of
document from attached List A or other document that demonstrates U.S. citizenship or
nationality and (2) Complete Section IV.
If you answered No: Complete Sections III and IV.
Name of document provided:
SECTION III – ALIEN STATUS
Are you an alien lawfully present in the United States? Yes/No
Chapter 7/Appendix B Medical Examiners
Supp. 12/31/18 A-54
If you answered Yes: (1) Provide an original (only in person at agency office) or legible copy of
the front and back (if any) of a document from attached List B or other document that
demonstrates lawful presence in the United States. (2) Complete Section IV. Information from
the documentation provided will be used to verify lawful presence through the United States
Government.
If you answered No: Complete Section IV.
Name of document provided:
SECTION IV -- DECLARATION
I declare under penalty of perjury under the laws of the State of Alabama that the answers and
evidence I provided are true and correct to the best of my knowledge.
APPLICANT’S SIGNATURE
DATE
LIST A
DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP
(1) The applicant's driver's license or nondriver's identification card issued by the division of
motor vehicles or the equivalent governmental agency of another state within the United
States if the agency indicates on the applicant's driver's license or nondriver's
identification card that the person has provided satisfactory proof of United States
citizenship.
(2) The applicant's birth certificate that satisfactorily verifies United States citizenship.
(3) Pertinent pages of the applicant's United States valid or expired passport identifying the
applicant and the applicant's passport number.
(4) The applicant's United States naturalization documents or the number of the certificate of
naturalization.
(5) Other documents or methods or proof of United States citizenship issued by the federal
government pursuant to the Immigration and Nationality Act of 1952, and amendments
thereto.
(6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or tribal
enrollment number.
(7) The applicant’s consular report of birth abroad of a citizen of the United States of
America.
(8) The applicant’s certificate of citizenship issued by the United States Citizenship and
Immigration Services.
(9) The applicant’s certification of report of birth issued by the United States Department of
State.
(10) The applicant’s American Indian card, with KIC classification, issued by the United
States Department of Homeland Security.
(11) The applicant’s final adoption decree showing the applicant’s name and United States
birthplace.
Medical Examiners Chapter 7/Appendix B
Supp. 12/31/18 A-55
(12) The applicant's official United States military record of service showing the applicant's
place of birth in the United States.
(13) An extract from a United States hospital record of birth created at the time of the
applicant's birth indicating the applicant's place of birth in the United States.
LIST B
DOCUMENTS INDICATING STATUS OF QUALIFIED
ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED
INTO U.S. FOR LESS THAN ONE YEAR
The documents listed below that are registration documents are indicated with an asterisk (“*”).
a. “Qualified Aliens”
Evidence of “Qualified Alien” status includes the following:
Alien Lawfully Admitted for Permanent Residence
· Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
· Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94.
Asylee
· * Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
· * Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”;
· * Form I-766 (Employment Authorization Document) annotated “A5”;
· Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or
· Order of an immigration judge granting asylum.
Refugee
· * FormI-94 annnotated with stamp showing admission under § 207 of the INA;
· * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
· * Form I-766 (Employment Authorization Document) annotated “A3”
Alien Paroled Into the U.S. for at Least One Year
· * Form I-94 with stamp showing admission for at least one year under section 212(d)(5)
of the INA. (Applicant cannot aggregate periods of admission for less than one year to
meet the one year requirement.)
Alien Whose Deportation or Removal Was Withheld
· * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10);
· * Form I-766 (Employment Authorization Document) annotated “A10”; or
· Order from an immigration judge showing deportation withheld under §243(h) of the
INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA.
Alien Granted Conditional Entry
· * Form I-94 with stamp showing admission under §203(a)(7) of the INA;
· * Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or
· * Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban/Haitian Entrant
· * Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”)
with the code CU6, CU7, or CH6;
Chapter 7/Appendix B Medical Examiners
Supp. 12/31/18 A-56
· Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code
CU6 or CU7; or
· Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5)
of the INA.
Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty
· U.S. Citizenship and Immigration Service petition and supporting documentation
540-X-7, APPENDIX C
Supp. 12/31/18 A-57
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX C
APPLICATION FOR REGISTRATION OF ANESTHESIOLOGIST ASSISTANT
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116
Application for Registration of Anesthesiologist Assistant
Under Alabama law, this document is a public record and will be provided upon request
Anesthesiologist
Supervising Anesthesiologist Name in Full
AL Medical License Number
Medical Specialty
Board Certified
Board Eligible
Principal Practice Location
Practice Name
Country
Street
Apt/Suite
City
State
Zip
Telephone Number
Is the anesthesiologist assistant for whom registration is sought employed by you or by your group,
partnership or professional corporation?
You answered No, a Supplemental Certificate must be submitted
Anesthesiologist Assistant
Assistant Name in Full
AL A. A. License Number
Anesthesiologist Assistant Job Description
Listed below are duties approved by the Board as a basic job description. Any additional duties requested
must be listed. Any additional duties must be individually considered and approved by the Board before
performing them.
Medical Examiners Chapter 7/Appendix C
Supp. 12/31/18 A-58
The following list includes the basic roles and functions to be performed by the Anesthesiologist
Assistant. The list includes the acts, tasks and functions which the AA will be allowed to perform under
supervision of an anesthesiologist, as well as those limited actions to be taken in life-threatening
emergency conditions.
1. Administers anesthesia under the supervision of an anesthesiologist.
2. Performs initial acute cardio-pulmonary resuscitation in life-threatening situations as directed by an
anesthesiologist.
3. Establishes multi-parameter monitoring of patients prior to, during and after anesthesia or in other
acute care situations. This may include invasive / non-invasive monitoring under the direct
supervision of an anesthesiologist. Also, other monitoring as may be developed for anesthesia and
intensive care use may be incorporated.
4. Manages perioperative anesthetic care, including ventilary support and other respiratory care
parameters as directed by an anesthesiologist.
5. Assists in research projects as carried out by an anesthesiologist.
6. Instructs others in principles and practices of anesthesia, respiratory care and cardio-pulmonary
resuscitation as directed by the anesthesiologist.
7. Assists an anesthesiologist in gathering routine perioperative data.
8. Provide emergency medical services in the event of declared national emergency or natural disaster
in accordance with the requirements of Board Rules.
9. The choice of anesthesia and drugs to be employed are prescribed by an anesthesiologist for each
patient except:
(a) where standard orders for the conduct of specified anesthetic are prescribed; and
(b) where life threatening emergencies arise necessitating the utilization of standard therapeutic
or resuscitation procedures. An anesthesiologist will be immediately available for
consultation regarding changes from standard procedures.
10. ADDITIONAL DUTIES REQUESTED FOR THE ANESTHESIOLOGIST ASSISTANT (i.e.
procedures requiring additional training). Provide, as an attachment to this Job Description,
documentation of the training and/or certification which qualifies the anesthesiologist assistant to
perform each additional duty/procedure which is requested. Training for the additional
duty/procedure shall have been previously approved by the Board pursuant to Board Rules.
Do you want to request approval to train for additional duty/procedure at this time?
11. List each practice site where this Job Description will be utilized.
Practice Site Address
Site Name
Country
Street
Apt/Suite
City
State
Zip
County
Phone Number
Number of hours the AA will be working at this site each week
We hereby certify under penalty of law of the State of Alabama that the foregoing information in this
Anesthesiologist Assistant Job Description is correct to the best of our knowledge and belief. We certify
that we have reviewed the current rules and regulations of the State of Alabama pertaining to
Chapter 540-X-7/Appendix C Medical Examiners
Supp. 12/31/18 A-59
anesthesiologist assistants and understand our responsibilities. We understand that we are equally
responsible for the actions of the Anesthesiologist Assistant.
Under Alabama law, this document is a public record and if requested it will be provided in its entirety.
I understand and agree that by typing my name, I am providing an electronic signature that has the same
legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing
information has been provided by me and is true and correct to the best of my knowledge, information
and belief.
Knowingly providing false information to the Alabama Board of Medical Examiners or Medical
Licensure Commission of Alabama could result in disciplinary action.
Medical Examiners Chapter 7/Appendix C
Supp. 12/31/18 A-60
SUPPLEMENTAL CERTIFICATE TO APPLICATION
FOR REGISTRATION AS AN ANESTHESIOLOGIST ASSISTANT
To:
(Name and Address of Hospital or Corporate Employer)
The State Board of Medical Examiners has been presented with an application from
for registration as an anesthesiologist
assistant to M.D. Information available to the Board
indicates that , M. D., is an employee of
(legal entity), and that
, Anesthesiologist Assistant, is an employee
of (legal entity).
To assist the Board in evaluating this application, it is requested that this questionnaire be filled out
and executed by the President, Chairman, Chief Executive Officer or Chief Administrative Officer of the
corporation or other legal entity that employs the anesthesiologist and the anesthesiologist assistant.
These questions relate directly to the supervisory relationship contemplated by Board Rules, Chapter
540-X-7. When an additional explanation is to be provided, please attach additional information on
separate pages.
1. Is the anesthesiologist whose name appears above, employed by you to engage in the full-time
practice of anesthesiology? If the answer to this question is no, please provide the Board with details
of the employment agreement between your corporation and the anesthesiologist.
2. Does the anesthesiologist whose name is stated above have the unqualified authority to terminate the
employment of the anesthesiologist assistant registered to him/her? If the answer to this question is
no, please set out in detail the steps required to terminate the employment of the anesthesiologist
assistant and identify the officer or officers of the corporation authorized to make that decision.
3. Does the anesthesiologist whose name is stated above, have the unqualified authority to determine the
levels of compensation to be paid to the anesthesiologist assistant registered to him/her? If the answer
to this question is no, please set forth in detail the manner in which the compensation of the
anesthesiologist assistant is established and the identification of the officer or officers of the
corporation who are authorized to establish increase or reduce the compensation of the
anesthesiologist assistant.
4. Does the anesthesiologist whose name appears above have the unqualified authority in matters
relating to patient care to enforce compliance with orders and directives issued to the anesthesiologist
assistant? Please describe in detail the manner in which such orders and directives may be enforced.
5. Is the anesthesiologist assistant whose name appears above subject to the supervision, direction or
control of any officer, director, supervisor or employee of the corporation other than the
anesthesiologist to whom he or she is registered? If the answer to this question is yes, please explain
in detail, identifying the individual exercising the supervision, direction or control and the
circumstances in which such supervision, direction and control would be exercised.
6. In matters relating to patient care, is the anesthesiologist assistant whose name appears above subject
to the immediate supervision, direction or control of any non-physician? If yes, explain the
relationship.
7. Will the anesthesiologist assistant whose name appears above be expected or required to perform any
part of his or her duties at any time when the anesthesiologist to whom he or she is registered is not on
duty and physically present on the premises of the hospital, clinic, or facility where the
Chapter 540-X-7/Appendix C Medical Examiners
Supp. 12/31/18 A-61
anesthesiologist assistant services will be rendered? If the answer to this question is yes, please
explain in detail all such circumstances.
I understand that the information submitted herein is to be used by the Board of Medical Examiners as
the basis for certification of an anesthesiologist assistant and that the furnishing of false or misleading
information or the future occurrence of substantial departures from or violations of the standards and
procedures outlined in this response, may be considered by the Board as grounds for termination of the
certification of the anesthesiologist assistant.
The undersigned hereby certifies that the foregoing information is true and correct to the best of my
knowledge, information and belief.
Name of the Corporation Title of Officer Signing Certificate
Printed Name of the Officers Signing Certificate Signature
This form should be completed, printed, and provided directly to the Alabama Board of Medical
Examiners. Facsimile and email of this form are accepted.
Chapter 7/Appendix D Medical Examiners
Supp. 12/31/18 A-62
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX D
ALABAMA BOARD OF MEDICAL XAMINERS
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116
APPLICATION FOR LICENSURE OF ANESTHESIOLOGIST ASSISTANT
Anesthesiologist Assistant’s Name Social Security Number*
*Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social
security number (SSN) on this application. The uses of your SSN are limited to the purpose of
administering the state child support program and intra-agency for identification purposes. If your SSN
is not provided, your application is not complete, and no license will be issued.
Place of Birth
Country of Birth
City of Birth
State/Province of Birth
Gender/Sex (at birth)
Date of Birth
Contact Information
The address and contact methods provided should be how the Board or Commission can contact the license
applicant directly. Please DO NOT provide contact information for office managers, assistants, or license
assistance companies.
Home Address
Country
Street
Apt/Suite
City
State
Zip
County
If you answer yes to any of the following questions, please provide a detailed explanation and provide the complete address of any psychiatrist/psychologist, state board, hospital, etc., if appropriate:
1. Have you ever been convicted of a felony?
2. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the
practice of medicine?
Medical Examiners Chapter 7/Appendix D
Supp. 12/31/18 A-63
3. Have you ever been convicted of any violation of a state or federal law relating to controlled
substances?
4. Have you ever been denied a state or federal controlled substance certificate?
5. Have you ever been denied prescription privileges for non-controlled or legend drugs by any state
or federal authority?
6. Has your certification or license to practice as an anesthesiologist assistant in any state
been suspended, revoked, restricted, curtailed, or voluntarily surrendered while under
investigation in any state?
7. Have your staff privileges at any hospital or health care facility been revoked,
suspended, curtailed, limited, placed under conditions restricting your practice, or
voluntarily surrendered while under investigation?
8. Have you ever been denied a certification or license to practice as an anesthesiologist
assistant in any state or has your application for certification or for a license to practice as
an anesthesiologist assistant been withdrawn under threat of denial?
9. Have you ever had a judgment rendered against you or action settled relating to the
performance of your professional service?
10. Have you successfully completed the Anesthesiologist Assistant National Certifying Examination?
You answered Yes, upload verifying documentation from the National Commission on
Certification of Anesthesiologist Assistants (NCCAA).
Have you ever taken the examination?
Are you registered to take the examination?
You answered Yes, upload verifying documentation from the NCCAA.
Test Date:
Chapter 7/Appendix D Medical Examiners
Supp. 12/31/18 A-64
11. Within the past five years, have you ever raised the issue of consumption of
drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral
disorder or condition as a defense, mitigation, or explanation for your
actions in the course of any administrative or judicial proceeding or
investigation; any inquiry or other proceeding; or any proposed termination
by an educational institution, employer, government agency, professional
organization or licensing authority?
12. Have you ever been diagnosed as having or have you ever been treated for
pedophilia, exhibitionism or voyeurism?
13. Are you currently* engaged in the excessive use of alcohol, controlled
substances, or the use of illegal drugs, or received any therapy or treatment
for alcohol or drug use, sexual boundary issues or mental health issues? (If
you are an anonymous participant in the Alabama Physician Health Program
and are in compliance with your contract, you may answer “No” to this
question, such answer for this purpose will not be deemed upon certification
as providing false information to the Alabama Board of Medical Examiners)
*The term “currently” does not mean on the day of, or even in the weeks or
months preceding the completion of this application. Rather, it means
recently enough so that the condition referred to may have an ongoing impact
on one’s functioning as an assistant to an anesthesiologist within the past two
years.
IMPORTANT: The Board recognizes that licensees encounter health
conditions, including those involving mental health and substance use
disorders, just as their patients and other health care providers do. The
Board expects its licensees to address their health concerns and ensure
patient safety. Options include anonymously self-referring to the Alabama
Physician Health Program (334-954-2596), a physician advocacy
organization dedicated to improving the health and wellness of medical
professionals in a confidential manner. The failure to adequately address a
health condition, where the licensee is unable to practice with reasonable
skill and safety to patients, can result in the Board taking action against the
license to practice as an anesthesiologist assistant.
Please initial certifying that you understand and acknowledge your duty as a
licensee to address any such condition as stated above.
14. Have you been, within the past five years, convicted of driving under the
influence (DUI) or have you been charged with DUI and been convicted of a
lesser offense such as reckless driving?
15. Has your medical training or medical practice been interrupted or suspended for
a period longer than 60 days for any reason other than a vacation?
Education Information
When entering dates attended in the education sections if you do not know the exact date use the first date
of the month. (Example: you attended from August 1990 – July 1994, enter 08/01/1990 – 07/01/1994)
Medical Examiners Chapter 7/Appendix D
Supp. 12/31/18 A-65
Applicant’s Education (since graduating from high school)
Upload a copy of your diploma(s) reflecting graduation from an Anesthesiologist Assistant Program
School Name
Start Date
End Date
School Address
Applicant’s Activities since graduating from high school (cover all time periods)
Place of Employment or Activity
Start Date
End Date
Address
CERTIFICATION of LICENSURE: (list all states where you have been
certified/registered/licensed as an Anesthesiologist Assistant). It is a requirement that each
state provide directly to the Board a verification. Copies via facsimile or email are accepted. It
is your responsibility to make the request to each state.
It is a requirement that each state provide a verification of licensure and return it directly to this agency
where it will be added to your application for licensure. It is your responsibility to make the request to each
state.
State
Affidavit and Release:
I, certify after being duly sworn, that all of the information
supplied in the submitted application is true and correct to the best of my knowledge, that the photograph
submitted is a true likeness of the assistant and was taken within sixty days prior to the date of this
application. I acknowledge that any false or untrue statement or representation made in this application
may result in the revocation of any certification / licensure granted.
I further authorize the release of this application and any information submitted with it or information
collected by the Alabama Board of Medical Examiners in connection with this application, including
derogatory information, to any person or organization having a legitimate need for the information and
release of the Alabama Board of Medical Examiners from all liability for the release of this information.
I further authorize the release of information, including derogatory information, which may be in the
possession of other individuals or organizations to the Alabama Board of Medical Examiners and release
this person or any organization from any liability for the release of information.
_____________________________________
Anesthesiologist Assistant’s Signature
Date: ____________________
County of ____________________________________________
State of ___________________________
Chapter 7/Appendix D Medical Examiners
Supp. 12/31/18 A-66
SWORN to and subscribed before me this _____ day of
________________________, _______
________________________________
Notary Public Signature
My Commission Expires: _______________
Under Alabama law, this document is a public record and will be provided upon request
The Alabama Board of Medical Examiners will enforce the Board’s rules and options for the
issuance of Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an
application.
Print affidavit and release, sign in presence of Notary Public, attach color picture if not uploaded, and
mail original to the Alabama Board of Medical Examiners.
Attach Photograph, if one was not uploaded.
Medical Examiners Chapter 7/Appendix E
Supp. 12/31/18 A-67
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX E
PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE RENEWAL
20XX Physician Assistant/Anesthesiologist Assistant License Renewal
Deadline: December 31, 20XX
Failure to apply for license renewal and pay renewal fee will result in the license automatically
being placed in an inactive status, making it illegal for the holder to practice as a Physician
Assistant/Anesthesiologist Assistant effective January 1, 20XX.
Under Alabama law, this document is a public record and will be provided upon request.
CME Certification: (Select One)
I hereby certify that I have met or will meet by December 31 the annual minimum
continuing education requirement of 25 AMA PRA Category I Credits™ or equivalent
continuing medical education for the calendar year 20XX and have or will have supporting
documentation if audited.
I hereby certify that I am exempt from the minimum continuing medical education
requirement for the following reason (Select One)
I received my initial license to practice in Alabama in the calendar year 20XX.
I am exempt from the CME requirement for the calendar year 20XX because I am a
member of a branch of the armed services and I was deployed for military service in the
calendar year 20XX.
I have obtained a waiver from the Board of Medical Examiners due to illness, disability or
other hardship condition which existed in the calendar year 20XX.
Professional Responsibility Certification
Please answer the following questions yes or no. If any answer is “yes,” please provide a detailed
explanation.
a. Have you been convicted of a felony within the past year?
b. Have you been convicted within the past year of a crime or offense (Felony or
misdemeanor) related to the practice of medicine?
c. Have you been convicted within the past year of any violation of a state or
federal law relating to controlled substances?
d. Within the past year, has your PA/AA certificate or license in any state been suspended,
revoked, restricted, curtailed, or voluntarily surrendered while under investigation?
e. Within the past year, have your privileges at any hospital or health care facility been
revoked, suspended, curtailed, limited, placed under conditions restricting your practice, or
voluntarily surrendered while under investigation?
Chapter 7/Appendix E Medical Examiners
Supp. 12/31/18 A-68
f. Have you been denied a PA/AA certificate or license in any state or has your application for a certificate or
license been withdrawn under threat of denial within the past year?
g. Have you had within the past year a judgment rendered against you or action settled relating to the
performance of your professional service?
h. Within the past two years, have you ever raised the issue of consumption of drugs or alcohol or the
issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation,
or explanation for your actions in the course of any administrative or judicial proceeding or
investigation; any inquiry or other proceeding; or any proposed termination by an educational
institution, employer, government agency, professional organization or licensing authority?
i. Within the past two years, have you been diagnosed as having or been treated for pedophilia,
exhibitionism, or voyeurism?
j. Since you last renewed have you engaged in the excessive use of alcohol, controlled substances, or
the use of illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual
boundary issues or mental health issues? (If you are an anonymous participant in the Alabama
Physician Health Program and are in compliance with your contract, you may answer “No” to this
question, such answer for this purpose will not be deemed upon certification as providing
false information to the Alabama Board of Medical Examiners).
If you answer “yes”, then a description is required.
k. Important: The Board recognizes that licensees encounter health conditions, including those
involving mental health and substance use disorders, just as their patients and other health care
providers do. The Board expects its licensees to address their health concerns and ensure patient
safety. Options include anonymously self-referring to the Alabama Physician Health Program
(334-954-2596), a physician advocacy organization dedicated to improving the health and wellness
of medical professionals in a confidential manner. The failure to adequately address a health
condition, where the licensee is unable to practice with reasonable skill and safety to
patients, can result in the Board taking action against the license to practice as an assistant to
physician.
______ Please initial certifying that you understand and acknowledge your duty as a licensee to address
any such condition as stated above.
*The term “currently” does not mean on the day of, or even in the weeks or months
preceding the completion of this application. Rather, it means recently enough that the
condition referred to may have an ongoing impact on one’s functioning as a physician
assistant/anesthesiologist assistant, or within the past two years.
l. Have you been, within the past year, convicted of driving under the influence (DUI) or have
you been charged with DUI and been convicted of a lesser offense such as reckless driving?
m. Has your medical training or medical practice been interrupted or suspended for a period
longer than 60 days for any reason other than a vacation or maternity leave?
Review the following Registration Agreements (RA) (If any):
Medical Examiners Chapter 7/Appendix E
Supp. 12/31/18 A-69
Is this Registration Agreement still Active?
How many hours per week do you work under this Registration Agreement?
Please provide a date of termination
What was the reason this Registration Agreement was terminated
I understand and agree that by typing my name, I am providing an electronic signature that has
the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I
attest that the foregoing information has been provided by me and is true and correct to the
best of my knowledge, information and belief.
Knowingly providing false information to the Alabama Board of Medical Examiners could
result in disciplinary action.
Chapter 7/Appendix F Medical Examiners
Supp. 12/31/18
A-70
ALABAMA BOARD OF MEDICAL EXAMINERS
APPENDIX F
APPLICATION FOR REINSTATEMENT OF
PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE
Under Alabama law, this document is a public record and will be provided upon request.
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116
APPLICATION FOR REINSTATEMENT OF
PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE
NAME
ADDRESS
INITIAL LICENSE NUMBER
ISSUE DATE
DATE OF REVOCATION/SUSPENSION/SURRENDER OF LICENSE:
REASONS FOR REVOCATION/SUSPENSION/VOLUNTARY SURRENDER OF LICENSE
(Please give detailed reasons)
Please answer yes or no to the following questions. If any answer is “yes,” provide a detailed
explanation.
1. Have you ever been convicted of a felony?
2. Have you ever been convicted of a crime or offense (felony or misdemeanor) related to
the practice of medicine?
3. Have you ever been convicted of any violation of a state or federal law relating to
controlled substances?
4. Have you ever been denied a state or federal controlled substance certificate?
5. Have you ever been denied prescription privileges for non-controlled or legend drugs by
any state or federal authority?
6. Has your certification or license to practice as a physician/anesthesiologist assistant in
any state been suspended, revoked, restricted, curtailed, or voluntarily surrendered while
under investigation in any state?
7. Have your staff privileges at any hospital or health care facility been revoked, suspended,
curtailed, limited, placed under conditions restricting your practice, or voluntarily
surrendered while under investigation?
8. Have you ever been denied a certification or license to practice as a
physician/anesthesiologist assistant in any state or has your application for certification or
for a license to practice as a physician/anesthesiologist assistant been withdrawn under
threat of denial?
9. Have you ever had a judgment rendered against you or action settled relating to the
performance of your professional service?
Medical Examiners Chapter 7/Appendix F
Supp. 12/31/18
A-71
10. Are you currently registered, certified to or working for any other primary supervising
physician/anesthesiologist in another state? ie, are you presently working as a
physician/anesthesiologist assistant? If so, answer yes.
If YES, list the name and principal practice location of each primary
supervising physician/anesthesiologist to whom you are certified. In addition,
state your designated working hours per week for each
physician/anesthesiologist listed.
11. Have you ever been certified as a physician/anesthesiologist assistant by the Alabama
Board of Medical Examiners in the past?
If YES, please list the names of the physicians/anesthesiologists?
12. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol
or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense,
mitigation, or explanation for your actions in the course of any administrative or judicial
proceeding or investigation; any inquiry or other proceeding; or any proposed termination by
an educational institution, employer, government agency, professional organization or
licensing authority?
13. Have you ever been diagnosed as having or have you ever been treated for pedophilia,
exhibitionism, or voyeurism?
14. Are you currently engaged in the excessive use of alcohol, controlled substances, or the use
of illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual
boundary issues or mental health issues? (If you are an anonymous participant in the
Alabama Physician Health Program and are in compliance with your contract, you may
answer "No" to this question, such answer for this purpose will not be deemed upon
certification as providing false information to the Alabama Board of Medical).
If you answer "Yes", then a description is required.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including
those involving mental health and substance use disorders, just as their patients and other
health care providers do. The Board expects its licensees to address their health concerns
and ensure patient safety. Options include anonymously self-referring to the Alabama
Physician Health Program (334-954-2596), a physician advocacy organization dedicated to
improving the health and wellness of medical professionals in a confidential manner. The
failure to adequately address a health condition, where the licensee is unable to practice with
reasonable skill and safety to patients, can result in the Board taking action against the
license to practice as an assistant to physician.
_______ Please initial certifying that you understand and acknowledge your duty as a
licensee to address any such condition as stated above. 1 The term “currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the condition referred to may have an ongoing impact on one’s functioning as an assistant to a physician
within the past two years.
15. Have you been, within the past five years, convicted of driving under the influence (DUI) or
have you been charged with DUI and been convicted of a lesser offense such as reckless driving?
16.Has your medical training or medical practice been interrupted or suspended for a period
longer than 60 days for any reason other than a vacation?
Please list all states in which you hold or have applied for licensure:
Chapter 7/Appendix F Medical Examiners
Supp. 12/31/18
A-72
I hereby certify that the information contained herein is true and accurate to the best of my ability.
Date
Applicant’s Signature
SWORN to and subscribed before me this _____ day of _____________________, 20____.
Notary Public
My commission expires:
I hereby authorize the release of any information, favorable or otherwise concerning me, in your files to
the Alabama Board of Medical Examiners. A photostat copy of this authorization shall be as valid as the
original.
Applicant’s Signature
Medical Examiners Chapter 7/Appendix F
Supp. 12/31/18
A-73
ALABAMA BOARD OF MEDICAL EXAMINERS
DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN
ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1621,
provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt
“qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens
paroled into the United States are eligible to receive covered state or local public benefits.
With certain exceptions, Ala. Code § 31-13-1, et. seq. prohibits aliens unlawfully present in the U.S. from receiving
state or local benefits. Every U.S. Citizen applying for a state or local public benefit must sign a declaration of
Citizenship, and the lawful presence of an alien in the U.S. must be verified by the Federal Government.
Act 2011-535 also requires every individual applying for a permit or license to demonstrate his/her U.S. citizenship
or if the applicant is an alien, he/she must demonstrate his/her lawful presence in the United States.
Directions: This form must be completed and submitted by individuals applying for licenses or permits.
SECTION 1 --- APPLICANT INFORMATION
NAME: __________________________________________________________________________________ (Print or Type) (Last) (First) (M.I.)
DATE OF BIRTH: ____________________________________________________________________________
SECTION II --- U.S. CITIZENSHIP OR NATIONAL STATUS
Are you a citizen or national of the United States (check one) ___ Yes ___ No
If you answered YES: (1) Provide an original (only in person at agency office) or legible copy of document from
attached List A or other document that demonstrates U.S. citizenship or nationality and (2) Complete Section IV.
If you answered No: Complete Sections III and IV.
Name of document provided: __________________________________________________________________
SECTION III – ALIEN STATUS Are you an alien lawfully present in the United States? ___ Yes ___ No
If you answered Yes: (1) Provide an original (only in person at agency office) or legible copy of the front and back
(if any) of a document from attached List B or other document that demonstrates lawful presence in the United
States. (2) Complete Section IV. Information from the documentation provided will be used to verify lawful
presence through the United States Government.
If you answered No: Complete Section IV.
Name of document provided: _________________________________________________________________.
SECTION IV -- DECLARATION I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided
are true and correct to the best of my knowledge.
__________________________________________________ _______________
APPLICANT’S SIGNATURE DATE
Chapter 7/Appendix F Medical Examiners
Supp. 12/31/18
A-74
LIST A
DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP
(1) The applicant's driver's license or nondriver's identification card issued by the
division of motor vehicles or the equivalent governmental agency of another state within the
United States if the agency indicates on the applicant's driver's license or nondriver's
identification card that the person has provided satisfactory proof of United States citizenship.
(2) The applicant's birth certificate that satisfactorily verifies United States
citizenship.
(3) Pertinent pages of the applicant's United States valid or expired passport
identifying the applicant and the applicant's passport number.
(4) The applicant's United States naturalization documents or the number of the
certificate of naturalization.
(5) Other documents or methods or proof of United States citizenship issued by the
federal government pursuant to the Immigration and Nationality Act of 1952, and amendments
thereto.
(6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number,
or tribal enrollment number.
(7) The applicant’s consular report of birth abroad of a citizen of the United States of
America.
(8) The applicant’s certificate of citizenship issued by the United States Citizenship
and Immigration Services.
(9) The applicant’s certification of report of birth issued by the United States Department
of State.
(10) The applicant’s American Indian card, with KIC classification, issued by the
United States Department of Homeland Security.
(11) The applicant’s final adoption decree showing the applicant’s name and United
States birthplace.
(12) The applicant's official United States military record of service showing the
applicant's place of birth in the United States.
(13) An extract from a United States hospital record of birth created at the time of the
applicant's birth indicating the applicant's place of birth in the United States.
Medical Examiners Chapter 7/Appendix F
Supp. 12/31/18
A-75
LIST B
DOCUMENTS INDICATING STATUS OF QUALIFIED
ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED
INTO U.S. FOR LESS THAN ONE YEAR
The documents listed below that are registration documents are indicated with an asterisk (“*”). a. “Qualified Aliens”
Evidence of “Qualified Alien” status includes the following:
Alien Lawfully Admitted for Permanent Residence • Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
• Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94.
Asylee • * Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
• * Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”;
• * Form I-766 (Employment Authorization Document) annotated “A5”;
• Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or
• Order of an immigration judge granting asylum.
Refugee • * FormI-94 annotated with stamp showing admission under § 207 of the INA;
• * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
• * Form I-766 (Employment Authorization Document) annotated “A3”
Alien Paroled Into the U.S. for at Least One Year • * Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA.
(Applicant cannot aggregate periods of admission for less than one year to meet the one year
requirement.)
Alien Whose Deportation or Removal Was Withheld • * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10);
• * Form I-766 (Employment Authorization Document) annotated “A10”; or
• Order from an immigration judge showing deportation withheld under §243(h) of the INA as in effect
prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA.
Alien Granted Conditional Entry • * Form I-94 with stamp showing admission under §203(a)(7) of the INA;
• * Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or
• * Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban / Haitian Entrant • * Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code
CU6, CU7, or CH6;
• Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code CU6 or CU7; or
• Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.
Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty
• U.S. Citizenship and Immigration Service petition and supporting documentation
Chapter 7/Appendix K Medical Examiners
Supp. 12/31/18
A-76
Author: Alabama State Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-293, 34-24-298, 34-24-299, 34-24-303, 34-24-306.
History: Repealed and Replaced (Entire Appendices for
Chapter 7): Filed September 21, 1998; effective
October 26, 1998. Amended (Appendices A - D for Chapter is
amended - Appendices E - J is new): Filed July 23, 1999;
effective August 27, 1999. Repealed and New Appendices (A-J):
Filed September 19, 2002; effective October 24, 2002. Amended
(Appendices I & J only): Filed May 21, 2004; effective
June 25, 2004. Amended (Appendices B & F only): Filed
November 19, 2004; effective December 24, 2004. Amended: Filed
April 13, 2006; effective May 18, 2006. Amended (Appendix A
only): Filed April 17, 2008; effective May 22, 2008. Amended
(Added New Appendix K only): Filed October 15, 2008; effective
November 19, 2008. Amended (Appendix B only): Filed
December 18, 2008; effective January 22, 2009. Amended (Appendix
I only): Filed July 16, 2009; effective August 20, 2009.
Repealed (Appendix J only): Filed August 5, 2009; effective
September 9, 2009. Amended (Appendix I only): Filed
November 18, 2009; effective December 23, 2009. Amended: Filed
March 11, 2010; effective April 15, 2010. Amended (Appendix B
only): Filed May 20, 2010; effective June 24, 2010. Amended
(Appendix I only): Filed October 21, 2010; effective
November 25, 2010. Amended (Appendix B only): Filed
December 16, 2010; effective January 20, 2011. Amended
(Appendices A, D, E, H, and K only): Filed February 17, 2012;
effective March 23, 2012. Amended (Appendices D and H only):
Filed August 16, 2012; effective September 23, 2012. Amended
(Appendices D and H only): Filed July 22, 2013; effective
August 26, 2013. Amended (Appendices D, H, I and K only): Filed
March 20, 2014; effective April 24, 2014. Amended (Appendix F
only): Filed July 21, 2016; effective September 4, 2016.
Repealed and New Rule (Appendix I only): Filed July 20, 2017;
effective September 3, 2017. Amended (Appendix A only): Filed
February 27, 2018; effective April 14, 2018. Repealed and New
Rule (Appendix B was repealed and Appendix D was renamed Appendix
B): Filed February 27, 2018; effective April 14, 2018. Repealed
and New Rule (Appendix C was repealed and Appendix E was renamed
Appendix C): Filed February 27, 2018; effective April 14, 2018.
Repealed and New Rule (Appendix D was repealed and Appendix H was
renamed Appendix D): Filed February 27, 2018; effective
April 14, 2018. Amended (Appendix I was renamed Appendix D):
Filed February 27, 2018; effective April 14, 2018. Repealed
(Appendix F only): Filed February 27, 2018; effective
April 14, 2018. Amended (Appendix K was renamed Appendix F):
Filed February 27, 2018; effective April 14, 2018. Repealed
Medical Examiners Chapter 7/Appendix K
Supp. 12/31/18
A-77
(Appendix G only): Filed February 27, 2018; effective
April 14, 2018. Amended (Appendices A - D only): Filed
August 22, 2018; effective October 6, 2018.
Chapter 11/Appendix A Medical Examiners
Supp. 12/31/18
A-78
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 11 - APPENDIX A
INITIAL SURVEY OF FOREIGN MEDICAL SCHOOLS
(REPEALED)
Author:
Statutory Authority:
History: Repealed: Filed May 20, 1996; effective June 24, 1996.
Medical Examiners Chapter 11/Appendix B
Supp. 12/31/18 A-79
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 11 - APPENDIX B
BY THE ALABAMA BOARD OF MEDICAL EXAMINERS DESCRIPTIVE DATA ON A
FOREIGN MEDICAL SCHOOL
(REPEALED)
Author:
Statutory Authority:
History: Repealed: Filed May 20, 1996; effective June 24, 1996.
Chapter 11/Appendix C Medical Examiners
Supp. 12/31/18 A-80
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 11 - APPENDIX C
STANDARDS FOR APPROVAL OF FOREIGN MEDICAL SCHOOLS
(REPEALED)
Author: Wendell R. Morgan
Statutory Authority: Code of Ala. 1975, §34-24-53; Act 87-775.
History: Filed January 20, 1988. Repealed: Filed May 20, 1996;
effective June 24, 1996.
Medical Examiners Chapter 11/Appendix D
Supp. 12/31/18 A-81
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 11 - APPENDIX D
PROCEDURES FOR THE SITE VISIT AND THE SITE VISIT TEAM
(REPEALED)
Author:
Statutory Authority:
History: Repealed: Filed May 20, 1996; effective June 24, 1996.
Medical Examiners Chapter 16/Appendix A
Supp. 12/31/18 A-82
ALABAMA BOARD OF MEDICAL EXAMINERS
ADMINISTRATIVE CODE
CHAPTER 16 - APPENDIX A
ALABAMA BOARD OF MEDICAL EXAMINERS
P.O. Box 946 - Montgomery, AL 36101 (334) 242-4116
Application for Certificate of Qualification for a Special Purpose License to
Practice Medicine or Osteopathy
To The Board of Medical Examiners of the State of Alabama:
I hereby make application for a certificate of qualification to practice medicine or osteopathy across state
lines in the State of Alabama, and submit the following statement concerning my qualifications for a
special purpose license
Name in Full
Social Security Number*
*Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social
security number (SSN) on this application. The uses of your SSN are limited to the purpose of
administering the state child support program and intra-agency for identification purposes. If your
SSN is not provided, your application is not complete, and no license will be issued.
Place of Birth
Country of Birth
City of Birth
State/Providence of Birth
Gender/Sex (at birth)
Date of Birth
Contact Information
The address and contact methods provided should be how the Board or Commission can contact the
license applicant directly. Please DO NOT provide contact information for office managers,
assistances, or license assistant companies.
Address
Contact Methods
Email Address
Home Telephone Number
Work Telephone Number
List all states where you are licensed to practice medicine or osteopathy. It is required that each state
complete one of the verification forms which will be attached to your application.
Answer yes or no (if any following answers are in the affirmative, please explain in detail and provide
the complete name and address of any state board, hospital, psychiatrist/psychologist, etc.)
1. Has your certificate of qualification or license to practice medicine in any state been suspended, revoked, restricted,
Chapter 16/Appendix A Medical Examiners
Supp. 12/31/18 A-83
curtailed or voluntarily surrendered under threat of suspension or revocation or disciplined in any manner? You answered Yes, please provide a description
2. Have you ever been denied a certificate of qualification or a license to practice medicine in any state or has your application for a certificate of qualification or license to practice medicine or osteopathy been withdrawn under threat of denial?
3. Has a disciplinary action been initiated in any state in which you
currently hold a license to practice medicine or osteopathy?
DECLARATION FOR CERTIFICATE OF QUALIFICATION FOR SPECIAL PURPOSE
LICENSE
In connection with my application for a certificate of qualification for a special purpose license to
practice medicine or osteopathy across state lines, I understand and acknowledge that:
a. A special purpose license only permits the holder to engage in the practice of medicine across state
lines on patients located in the State of Alabama but does not authorize the holder to be physically
present and engage in the general practice of medicine within the State of Alabama.
b. It is the affirmative duty of the holder of a special purpose license to report to the Alabama Board of Medical Examiners in writing within fifteen days of the initiation of any disciplinary action against the license to practice medicine or osteopathy of the licensee by any state or territory in which the license is licensed.
c. By accepting a special purpose license, the licensee agrees to produce patient records or materials
as requested by the Board of Medical Examiners or the Medical Licensure Commission and to appear before the Board or the Commission or any of its committees following the receipt of a written notice by the Board or Commission.
d. The issuance of a special purpose license subjects the licensee to the jurisdiction of the Alabama Board of Medical Examiners and the Medical Licensure Commission of Alabama and the respective statutes and regulations under which they operate, including all matters related to discipline.
e. Failure to renew a special purpose license according to the renewal schedule shall result in the
automatic revocation of the special purpose license. In the event of the automatic revocation of a
special purpose license for failure to renew, the licensee must reapply for a new special purpose
license.
Medical Examiners Chapter 16/Appendix A
Supp. 12/31/18 A-84
AFFIDAVIT AND RELEASE
I, , certify, after being duly sworn, that all of
the information supplied in the submitted application is true and correct to the best of my
knowledge . I acknowledge that any false or untrue statement or representation made in this
application may result in the revocation of the license granted to me and criminal prosecution to
the fullest extent of the law.
I further authorize the release of this application and any information submitted with it or
information collected by the Alabama Board of Medical Examiners in connection with this
application, including derogatory information to any person or organization having a legitimate
need for the information and release the Alabama Board of Medical Examiners from all liability
for the release of this information.
I further authorize the release of information, including derogatory information, which may be
in the possession of other individuals or organizations to the Alabama Board of Medical
Examiners and release this person or any organization from any liability for the release of
information.
_________________________________________
Applicant’s signature
Date: ____________________ County of ____________________________________________
State of ___________________________
SWORN to and subscribed before me this _____ day of ________________________, _______
________________________________
Notary Public Signature
My Commission Expires: _______________
Under Alabama law, this document is a public record and will be provided upon request.
Attach Photograph If one was not uploaded
Chapter 16/Appendix A Medical Examiners
Supp. 12/31/18 A-85
The Alabama Board of Medical Examiners will enforce the Board’s rules and options for the
issuance of Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an
application.
Print affidavit and release, sign in presence of Notary Public, attach color picture if not uploaded, and
return original to the Alabama Board of Medical Examiners.
Medical Examiners Chapter 16/Appendix A
Supp. 12/31/18 A-86
ALABAMA BOARD OF MEDICAL EXAMINERS DECLARATION OF
CITIZENSHIP AND LAWFUL PRESENCE OF AN ALIEN FOR PUBLIC
BENEFITS AND LICENSING/PERMITTING PROGRAMS
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of
1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens,
United States non-citizen nationals, non-exempt “qualified aliens” (and sometimes only
particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the
United States are eligible to receive covered state or local public benefits.
With certain exceptions, Ala. Code §§ 31-13-1, et. seq., prohibits aliens unlawfully present
in the U.S. from receiving state or local benefits. Every U.S. Citizen applying for a state or
local public benefit must sign a declaration of Citizenship, and the lawful presence of an
alien in the U.S. must be verified by the Federal Government.
Ala. Code §§ 31-13-1, et. seq., also requires every individual applying for a permit or license to
demonstrate his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate
his/her lawful presence in the United States.
Directions: This form must be completed and submitted by individuals applying for
licenses or permits.
NAME: (Print or Type) (Last) (First) (M.I.)
DATE OF BIRTH:
Are you a citizen or national of the United States (check one) Yes No
If you answered YES: (1) Provide an original (only in person at agency office) or legible
copy of document from attached List A or other document that demonstrates U.S.
citizenship or nationality and (2) Complete Section IV.
If you answered No: Complete Sections III and IV. Name of document provided:
Are you an alien lawfully present in the United States? Yes No
If you answered Yes: (1) Provide an original (only in person at agency office) or legible
copy of the front and back (if any) of a document from attached List B or other document
that demonstrates lawful presence in the United States. (2) Complete Section IV.
SECTION 1 --- APPLICANT INFORMATION
SECTION II --- U.S. CITIZENSHIP OR NATIONAL STATUS
SECTION III – ALIEN
STATUS
Chapter 16/Appendix A Medical Examiners
Supp. 12/31/18 A-87
Information from the documentation provided will be used to verify lawful presence through
the United States Government.
If you answered No: Complete Section IV. Name of document provided: .
I declare under penalty of perjury under the laws of the State of Alabama that the answers
and evidence I provided are true and correct to the best of my knowledge.
APPLICANT’S SIGNATURE DATE
SECTION IV --
DECLARATION
Medical Examiners Chapter 16/Appendix A
Supp. 12/31/18 A-88
LIST A
DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP
(1) The applicant's driver's license or nondriver's identification card issued by the division of motor
vehicles or the equivalent governmental agency of another state within the United States if the
agency indicates on the applicant's driver's license or nondriver's identification card that the
person has provided satisfactory proof of United States citizenship.
(2) The applicant's birth certificate that satisfactorily verifies United States citizenship.
(3) Pertinent pages of the applicant's United States valid or expired passport
identifying the applicant and the applicant's passport number.
(4) The applicant's United States naturalization documents or the number of the
certificate of naturalization.
(5) Other documents or methods or proof of United States citizenship issued by the
federal government pursuant to the Immigration and Nationality Act of 1952, and
amendments thereto.
(6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or
tribal enrollment number.
(7) The applicant’s consular report of birth abroad of a citizen of the United States of America.
(8) The applicant’s certificate of citizenship issued by the United States
Citizenship and Immigration Services.
(9) The applicant’s certification of report of birth issued by the United States Department of State.
(10) The applicant’s American Indian card, with KIC classification, issued by the United
States Department of Homeland Security.
(11) The applicant’s final adoption decree showing the applicant’s name and United
States birthplace.
(12) The applicant's official United States military record of service showing the applicant's
place of birth in the United States.
(13) An extract from a United States hospital record of birth created at the time of the
applicant's birth indicating the applicant's place of birth in the United States.
Ala. Act #2011-535, Section 30(c) and Section 29(k).
Medical Examiners Chapter 16/Appendix A
Supp. 12/31/18 A-89
LIST B
DOCUMENTS INDICATING STATUS OF QUALIFIED ALIENS, NONIMMIGRANTS, AND
ALIENS PAROLED INTO U.S. FOR LESS THAN ONE YEAR
The documents listed below that are registration documents are indicated with an asterisk (“*”).
a. “Qualified Aliens”
Evidence of “Qualified Alien” status
includes the following: Alien Lawfully
Admitted for Permanent Residence
• Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
• Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94.
Asylee
• *Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
• *Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”;
• *Form I-766 (Employment Authorization Document) annotated “A5”;
• Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or
• Order of an immigration judge granting asylum.
Refugee
• *FormI-94 annnotated with stamp showing admission under § 207 of the INA;
• *Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
• *Form I-766 (Employment Authorization Document) annotated “A3”
Alien Paroled Into the U.S. for at Least One Year
• *Form I-94 with stamp showing admission for at least one year under section 212(d)(5)
of the INA. (Applicant cannot aggregate periods of admission for less than one year to
meet the one year requirement.)
Alien Whose Deportation or Removal Was Withheld
• *Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10);
• *Form I-766 (Employment Authorization Document) annotated “A10”; or
• Order from an immigration judge showing deportation withheld under §243(h) of the
INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the
INA.
Alien Granted Conditional Entry
• *Form I-94 with stamp showing admission under §203(a)(7) of the INA;
• *Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or
• *Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban / Haitian Entrant
• *Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with
the code CU6, CU7, or CH6;
• Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code CU6
or CU7; or
• Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section
212(d)(5) of the INA.
Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty
• U.S. Citizenship and Immigration Service petition and supporting documentation
Chapter 16/Appendix A Medical Examiners
Supp. 12/31/18 A-90
Author: Alabama Board of Medical Examiners
Statutory Authority: §§34-24-303
History: New Appendix: Filed February 17, 2012; effective
March 23, 2012. Amended: Filed July 22, 2013; effective
August 26, 2013. Amended: August 23, 2018; effective
October 7, 2018.