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

Ala. Code § 34-24-75.1 requires that all physicians holding limited licenses under the retired senior volunteer program apply for renewal of the certificate of qualification prior to renewal of the license. Once the application has been completed, please return it to the qualified clinic or nonprofit organization to obtain certification.

Required demographic information:

Full name

Alternate name

Name of qualified clinic or nonprofit organization

License number

Date issued

Required background information:

If your answer is “yes,” please provide a detailed explanation in the space provided.

Legal:

1. 1. Have you ever 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 medicine or state or federal controlled substances laws, or driving under the influence (DUI)?

   *This question excludes minor traffic violations such as speeding and parking tickets but includes felony and misdemeanor criminal matters that have been dismissed, expunged, sealed, subject to a diversion or deferred prosecution program, or otherwise set aside.

2. 2. Have you ever been arrested for, cited for, charged with, or convicted of any sex offender laws or required to register as a sex offender for any reason?
3. 3. Have you ever had a judgment rendered against you or action settled relating to an action for injury, damages, or wrongful death for breach of the standard of care in the performance of your professional service (“malpractice”)?

4. 4. To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any law enforcement agency?

   Administrative/Regulatory:

5. 5. Have you ever had any Drug Enforcement Administration registration and/or state controlled substances registration denied, voluntarily surrendered while under investigation, or subject to any discipline, including, but not limited to revocation, suspension, probation, restriction, conditions, reprimand, or fine?
6. 6. Have you ever been denied a license to practice medicine in any state or jurisdiction or has your application for a license to practice medicine been withdrawn under threat of denial?
7. 7. Has your certificate of qualification or license to practice medicine in any state or jurisdiction ever been subject to any discipline, including but not limited to revocation, suspension, probation, restrictions, conditions, reprimand, or fine?
8. 8. Have your staff privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?

9. 9. To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any federal agency, any licensing board/agency, or any hospital or health care facility?

   Fitness to Practice:

10. 10. Are you currently suffering from any condition that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner?
11. 11. Within the past five years, have you raised the issue of any physical or psychiatric health disorder as a defense, mitigation, or explanation for your 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?

12. 12. The Board recognizes that licensees 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 licensees to address their health concerns, both mental and physical, in a timely manner to ensure patient safety. Licensees should seek appropriate medical care and should limit their medical practice when appropriate and as needed. The Board encourages licensees to utilize the services of the Alabama Professionals Health Program, 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.

    I have read and understand the statements above.

    [Applicant Attestation]

    Education/Training/Experience:

13. 13. As of the date of this application, has it been more than two years since the last time you were actively engaged in clinical practice or direct patient care?

14. 14. Has your medical education, training, or medical practice been interrupted or suspended, or have you ceased to engage in direct patient care, for a period longer than 60 days for any reason other than a vacation or for the birth or adoption of a child?

    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.

    Date

    Applicant’s typed name

    Certification of qualified clinic or nonprofit organization

    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 is true and correct to the best of my knowledge, information and belief.

    Date

    Clinic or Facility Administrator’s typed name

Author: Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73, 34-24-75.

Editor’s 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.

History: 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. Amended: Published February 28, 2020; effective April 13, 2020. Amended: Published December 30, 2022; effective February 13, 2023. Repealed and New Rule: Published March 31, 2025; effective May 15, 2025.