ALABAMA BOARD OF MEDICAL EXAMINERS
P.O.Box 946 – Montgomery, Alabama 36101 • 848 Washington Avenue - 36104 

Application for Alabama Pain Management Registration

 **Separate registration required for each location where pain management services are provided**

Registration Fees: $100.00 for first location; no additional charge for each additional location

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

Name
AL License Number
Alabama Controlled Substances Certificate Number
Expiration Date
DEA Number:
DEA Expiration Date:
DEA “X” Number (if applicable)
Expiration Date

1 Are you registered with PDMP?                        [ ] Yes [ ] No
(Upload copy of PDMP registration receipt)

2 Have you ever had a controlled substance registration
certificate denied, restricted or disciplined?         [ ] Yes [ ] No
You answered yes, please provide a summary of each action including the year, state and description of each action.

3 Have you ever had a disciplinary action taken against
your medical license in Alabama or any other state?    [ ] Yes [ ] No
You answered yes, please provide an explanation of the action, including the year, state and description of each action.

Please provide the following information for the above location where you provide pain management services:

Facility Name
Facility Physical Address:
The facility is owned or operated by:
A business entity qualifying under Ala. Code § 34-25-605(a)(2)
Name of business entity
List all persons or entities having an interest in the facility
Upload a copy of the articles of formation as filed with the Alabama
Secretary of State.
You answered no, please provide the following information
A physician licensed to practice medicine in Alabama

List all Owners, Operators of the facility
A governmental entity or body, or political subdivision, or any
combination thereof, including state universities and schools.
Full Name of Medical Director:

Please identify with supporting documentation, the criteria under which the listed medical directory qualifies to serve as the medical director, which can be found at Ala. Admin. Code § 540-X-19-.05

Upload Supporting Documentation

List all physicians providing pain management services at this location: I swear (affirm) that the information set forth on this application for Alabama Pain Management Registration form is true and correct to the best of my knowledge, information and belief. I also understand that the Board of Medical Examiners may conduct an on-site inspection of my records at any time.

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.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§20-2-250, et. seq.; Act 2013-223.

History: New Rule: Filed November 14, 2013; effective December 29, 2013. Amended: Filed June 19, 2014; effective July 24, 2014. Amended: Filed September 17, 2015; effective October 22, 2015. Amended: Filed August 23, 2018; effective October 7, 2018.