An applicant for an Alabama Controlled Substances Certificate shall disclose whether:

1. (1) Applicant's privilege for dispensing or prescribing controlled substances has ever been suspended, restricted, voluntarily surrendered while under investigation or revoked in any state.
2. (2) Applicant has ever been convicted of any state or federal crime relating to any controlled substance or driving under the influence (DUI).
3. (3) Any Federal Drug Enforcement Administration registration ever held by applicant has ever been suspended, restricted, revoked, or voluntarily surrendered while under investigation.
4. (4) Applicant's staff privileges at any hospitals have ever been suspended, restricted, or revoked for any reason related to the prescribing or dispensing of controlled substances.
5. (5) Applicant is 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.
6. (6) Within the past five years, applicant has 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.

7. (7) Applicant attests to this statement:

   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.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §20-2-51.

History: Filed November 9, 1982, as Rule No. 540-X-2-.25. Readopted: Filed February 8, 1983. Rules reorganized--rule number changed to 540-X-4-.02 (see conversion table at end of code): Filed June 14, 1984 (without publication in AAM). Amended: Filed February 21, 1986. Amended: Published December 30, 2022; effective February 13, 2023. Amended: Published March 31, 2025; effective May 15, 2025.