Medical Examiners Chapter 1/Appendix A ALABAMA STATE BOARD OF

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(Repealed 9/2/18)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Chapter 11 (Repealed Effective 6/24/96)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)


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


ADMINISTRATIVE CODE

CHAPTER 3 – APPENDIX A


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


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


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


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


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


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.


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: ______


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


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


ADMINISTRATIVE CODE

CHAPTER 3 – APPENDIX B

APPLICATION FOR A LIMITED CERTIFICATE OF QUALIFICATION


Supp. 6/30/19 A-15


Supp. 6/30/19 A-16


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;


Medical Examiners Chapter 3/Appendix C

Supp. 12/31/18 A-18


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)


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


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.


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.


Supp. 12/31/18 A-22


Date: ____________________ County of ________________________________________

State of ___________________________

SWORN to and subscribed before me this _____ day of ______________________, _______

________________________________ Notary Public Signature

My Commission Expires:____________


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.



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


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


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


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


Supp. 12/31/18 A-27

Author: Board of Medical Examiners


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


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


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;


Medical Examiners Chapter 3/Appendix D

Supp. 12/31/18 A-28


ADMINISTRATIVE CODE

CHAPTER 3 - APPENDIX D

Under Alabama law, this document is a public record and will be provided upon request


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


*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


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


Supp. 12/31/18 A-30



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


ADMINISTRATIVE CODE

CHAPTER 3 - APPENDIX E

Limited Certificate of Qualification Renewal Application

Medical Examiners Chapter 3- Appendix E

Supp. 6/30/19 A-32


Supp. 6/30/19 A-33


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 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;


Chapter 3/Appendix F Medical Examiners

Supp. 12/31/18 A-34


ADMINISTRATIVE CODE

CHAPTER 3 - APPENDIX F


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):





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?





educational institution; employer; government agency; professional organization; or licensing

authority?

Medical Examiners Chapter 3 - Appendix F

Supp. 12/31/18 A-35






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.







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




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




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.


Sworn to and subscribed before me this ___ day of ____________, 20___.

Notary Public

My commission expires: _____


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.



Supp. 12/31/18 A-36



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;


Ed. Note: Appendix F was renamed Appendix D, and Appendix H was

renamed Appendix F per certification filed February 27, 2018;


Medical Examiners Chapter 4 - Appendix A

Supp. 12/31/18 A-37


ADMINISTRATIVE CODE

CHAPTER 4 - APPENDIX A


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


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)



may have an ongoing impact on one’s functioning as a physician within the last two years.


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


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.


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


ADMINISTRATIVE CODE


Chapter 4 - Appendix C Medical Examiners

Supp. 12/31/18 A-42


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.


Supp. 12/31/18 A-43


APPENDIX A


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.


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.


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.


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.


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.


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.


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)


Supp. 12/31/18 A-49


APPENDIX B


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



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:





substances?


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?


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.





educational institution, employer, government agency, professional organization or licensing

authority?


exhibitionism or voyeurism?




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.


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.







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.


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





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


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.




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




Supp. 12/31/18 A-52

________________________________

Physician Assistant’s Signature

Date: ____________________ County of ____________________________________________

State of ___________________________


___________________________, _______

____________________________________


My Commission Expires: ________________

Under Alabama law, this document is a public record and will

be provided upon request



application.


mail original to the Alabama Board of Medical Examiners.

Attach Photograph, if one was not uploaded.


Supp. 12/31/18 A-53


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


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.


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;


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


APPENDIX C

APPLICATION FOR REGISTRATION OF ANESTHESIOLOGIST ASSISTANT



Application for Registration of Anesthesiologist Assistant


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.


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.


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


APPENDIX D

ALABAMA BOARD OF MEDICAL XAMINERS


APPLICATION FOR LICENSURE OF ANESTHESIOLOGIST ASSISTANT

Anesthesiologist Assistant’s Name Social Security Number*



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



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:





Supp. 12/31/18 A-63


substances?


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:


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.


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?


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)


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


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.




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



_____________________________________

Anesthesiologist Assistant’s Signature

Date: ____________________

County of ____________________________________________

State of ___________________________


Supp. 12/31/18 A-66


________________________, _______

________________________________


My Commission Expires: _______________




application.


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


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.


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?


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


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,


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




(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


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.


Supp. 12/31/18

A-70


APPENDIX F

APPLICATION FOR REINSTATEMENT OF

PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE




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.


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?


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?


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


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,


proceeding or investigation; any inquiry or other proceeding; or any proposed termination by

an educational institution, employer, government agency, professional organization or

licensing authority?



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:


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


Supp. 12/31/18

A-73


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.


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: __________________________________________________________________

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


Supp. 12/31/18

A-74

LIST A


(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.




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.


• U.S. Citizenship and Immigration Service petition and supporting documentation

Chapter 7/Appendix K Medical Examiners

Supp. 12/31/18

A-76


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


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


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.


Supp. 12/31/18

A-78


ADMINISTRATIVE CODE


INITIAL SURVEY OF FOREIGN MEDICAL SCHOOLS

(REPEALED)

Author:


History: Repealed: Filed May 20, 1996; effective June 24, 1996.


Supp. 12/31/18 A-79


ADMINISTRATIVE CODE

CHAPTER 11 - APPENDIX B

BY THE ALABAMA BOARD OF MEDICAL EXAMINERS DESCRIPTIVE DATA ON A

FOREIGN MEDICAL SCHOOL

(REPEALED)

Author:




Supp. 12/31/18 A-80


ADMINISTRATIVE CODE


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.


Supp. 12/31/18 A-81


ADMINISTRATIVE CODE

CHAPTER 11 - APPENDIX D

PROCEDURES FOR THE SITE VISIT AND THE SITE VISIT TEAM

(REPEALED)

Author:




Supp. 12/31/18 A-82


ADMINISTRATIVE CODE



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*



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


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,


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.


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.

_________________________________________


Date: ____________________ County of ____________________________________________

State of ___________________________

SWORN to and subscribed before me this _____ day of ________________________, _______

________________________________


My Commission Expires: _______________




Supp. 12/31/18 A-85



application.


return original to the Alabama Board of Medical Examiners.


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 III – ALIEN

STATUS


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


Supp. 12/31/18 A-88

LIST A


(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.



Ala. Act #2011-535, Section 30(c) and Section 29(k).


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.


• U.S. Citizenship and Immigration Service petition and supporting documentation


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


August 26, 2013. Amended: August 23, 2018; effective

October 7, 2018.

Documents

Medical Examiners Chapter 1/Appendix A ALABAMA STATE BOARD OF