An application to participate in the professional liability coverage program for a retired physician or dentist who volunteers at an established free medical clinic shall be completed and submitted to the Department. The following information may be required in the application:

1. (a) Name, addresses, phone numbers, and e-mail addresses of the applicant.
2. (b) Educational background and qualifications of the applicant.
3. (c) Area of practice of the applicant.
4. (d) State of Alabama medical or dentistry license number of the applicant.
5. (e) Name, address, phone numbers and e-mail addresses of the established free medical clinic.
6. (f) The number of hours the established free medical clinic will be open to the public.
7. (g) The applicant’s practice agreement with the established free medical clinic.
8. (h) The number of hours the applicant will volunteer to work at the established free medical clinic.
9. (i) Number of patients that visit the established free medical clinic annually.
10. (j) Attestation of compliances with these rules.
11. (k) Statements of assurance.
12. (l) Signature and/or initials of the applicant, as well as dates.

Author: John R. Wible

Statutory Authority: Code of Ala. 1975, §§22-2-2(6), 36-1-6.1

History: New Rule: Filed September 17, 2010; effective October 22, 2010.