1. (1) The applicant shall disclose whether:

   1. (a) Applicant's privilege for dispensing or prescribing controlled substances has ever been suspended, restricted, voluntarily surrendered while under investigation, revoked, or disciplined in any manner in any state or U.S. territory.
   2. (b) Applicant has ever been been arrested for, cited for, charged with, or convicted of any crime, offense, or violation of any law, felony, or misdemeanor, including, but not limited to, offenses related to the practice of professional healthcare, state or federal controlled substances laws, or driving under the influence (DUI)?
   3. (c) Any Federal Drug Enforcement Administration registration ever held by applicant has ever been suspended, restricted, revoked or voluntarily surrendered while under investigation.
   4. (d) Applicant's privileges at any hospitals have ever been suspended, restricted, revoked, or disciplined in any manner for any reason related to the prescribing or dispensing of controlled substances.
   5. (e) Applicant is currently suffering from any condition that impairs their judgment or that would otherwise adversely affect their ability to practice in a competent, ethical, and professional manner.
   6. (f) Within the past five years, applicant has raised the issue of any physical or psychiatric health disorder as a defense, mitigation, or explanation for their actions during 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.

   7. (g) Applicant has attested to have read and understood the following statement:

      The Board recognizes that permittees encounter potentially impairing health conditions just as their patients and other health care providers do, including psychiatric or physical illnesses which may impact cognition, as well as substance use disorders. The Board expects its permittees to address their health concerns, both mental and physical, in a timely manner to ensure patient safety. Permittees should seek appropriate medical care and should limit their practice when appropriate and as needed. The Board encourages permittees to utilize the services of the Alabama Board of Nursing's Voluntary Disciplinary Alternative Program, an advocacy organization dedicated to improving the health and wellness of nursing professionals in a confidential manner. The failure to adequately address a health condition, where the permittee is unable to practice with reasonable skill and safety to patients, can result in the Board taking action against the Qualified Alabama Controlled Substances Certificate.

   8. (h) Any disciplinary action has been taken or is pending against applicant with the Alabama Board of Nursing or any other licensing authority of any state, territory, or country.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§20-2-60, et seq.

History: New Rule: Publication December 30, 2022; effective February 13, 2023. Amended: Published December 29, 2023; effective February 12, 2024. Amended: Published March 31, 2025; effective May 15, 2025.