Limited Certificate of Qualification Renewal Application

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

If you meet the qualifications for a full medical license, you do not qualify for a limited license.

Section 34-24-75, Code of Alabama 1975, as amended, requires that all physicians holding a limited license apply to the Board of Medical Examiners for the renewal of their certificate of qualification prior to renewal of the license. Once the application has been completed, return it to the institution for the certification of the Dean, Program Director, Chief Medical Officer, or authorized State Institution individual.

Required demographic information:

Name in Full

Alternate name(s) used

Name of Institution

Home address

Telephone number (H/C)

Email address

License Number

Date Issued

Type of Limited License: (Please Choose One):

Resident

For yes, number of years in current residency program

Fellow

For yes, number of years in current fellowship program

Specialty Professor

For yes, number of years in current teaching position

Distinguished Professor

For yes, number of years in current teaching position

Visiting Professor

For yes, number of years in current teaching position

State Institution

For yes, number of years in current position

Required program/institution information

Do you limit your practice to the confines of the program/institution?

If the answer is no, please explain.

If applicable, list each United States Licensing Examination (USMLE) Steps you have passed and the date passed.

USMLE Step 1 _________________________

USMLE Step 2 _________________________

USMLE Step 3 _________________________

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 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?

2. 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”)?

3. 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:

4. 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?
5. 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?
6. 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?
7. 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?

8. 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:

9. 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?
10. 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?

11. 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 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

    Date

    Typed Name of Dean, Program Director, Chief Medical Officer, Warden, Medical Director

    Name of Program or State Institution

Author: Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§34-24-53.1, 34-24-70.

Editor’s Note: Appendix E was renamed Appendix C, and Appendix G was renamed Appendix E per certification filed February 27, 2018; effective April 14, 2018.

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 27, 2018; effective April 14, 2018. Amended: Filed February 20, 2019; effective April 7, 2019. Amended: Published February 28, 2020; effective April 13, 2020. Repealed and New Rule: Published December 30, 2022; effective February 13, 2023. Repealed and New Rule: Published March 31, 2025; effective May 15, 2025.