ALABAMA BOARD OF MEDICAL EXAMINERS Appendix CApplication for REGISTRATION OF ANESTHESIOLOGIST ASSISTANT ALABAMA BOARD OF MEDICAL EXAMINERSP.O. Box 946 / Montgomery, AL 36101‑0946 / (334) 242‑4116 Application for Registration of Anesthesiologist Assistant Under Alabama law, this document is a public record and will be provided upon request AnesthesiologistSupervising Anesthesiologist Name in FullAL Medical License NumberMedical SpecialtyBoard CertifiedBoard Eligible Principal Practice Location Practice NameCountryStreetApt/SuiteCityStateZipTelephone Number Is the anesthesiologist assistant for whom registration is sought employed by you or by your group, partnership or professional corporation?You answered No, a Supplemental Certificate must be submitted Anesthesiologist AssistantAssistant Name in FullAL A. A.  License Number

Anesthesiologist Assistant Job Description Listed below are duties approved by the Board as a basic job description. Any additional duties requested must be listed. Any additional duties must be individually considered and approved by the Board before performing them. The following list includes the basic roles and functions to be performed by the Anesthesiologist Assistant. The list includes the acts, tasks and functions which the AA will be allowed to perform under supervision of an anesthesiologist, as well as those limited actions to be taken in life‑threatening emergency conditions. 1. Administers anesthesia under the supervision of an anesthesiologist.2. Performs initial acute cardio‑pulmonary resuscitation in life‑threatening situations as directed by an anesthesiologist.3. Establishes multi‑parameter monitoring of patients prior to, during and after anesthesia or in other acute care situations. This may include invasive / non‑invasive monitoring under the direct supervision of an anesthesiologist. Also, other monitoring as may be developed for anesthesia and intensive care use may be incorporated.4. Manages perioperative anesthetic care, including ventilary support and other respiratory care parameters as directed by an anesthesiologist.5. Assists in research projects as carried out by an anesthesiologist.6. Instructs others in principles and practices of anesthesia, respiratory care and cardio‑pulmonary resuscitation as directed by the anesthesiologist.7. Assists an anesthesiologist in gathering routine perioperative data.8. Provide emergency medical services in the event of declared national emergency or natural disaster in accordance with the requirements of Board Rules.9. The choice of anesthesia and drugs to be employed are prescribed by an anesthesiologist for each patient except:(a)  where standard orders for the conduct of specified anesthetic are prescribed; and(b)  where life threatening emergencies arise necessitating the utilization of standard therapeutic or resuscitation procedures. An anesthesiologist will be immediately available for consultation regarding changes from standard procedures. 10. ADDITIONAL DUTIES REQUESTED FOR THE ANESTHESIOLOGIST ASSISTANT (i.e. procedures requiring additional training).  Provide, as an attachment to this Job Description, documentation of the training and/or certification which qualifies the anesthesiologist assistant to perform each additional duty/procedure which is requested.  Training for the additional duty/procedure shall have been previously approved by the Board pursuant to Board Rules.   Do you want to request approval to train for additional duty/procedure at this time?11. List each practice site where this Job Description will be utilized.      Practice Site Address      Site Name      Country      Street      Apt/Suite      City      State      Zip      County      Phone Number      Number of hours the AA will be working at this site each week We hereby certify under penalty of law of the State of Alabama that the foregoing information in this Anesthesiologist Assistant Job Description is correct to the best of our knowledge and belief. We certify that we have reviewed the current rules and regulations of the State of Alabama pertaining to anesthesiologist assistants and understand our responsibilities. We understand that we are equally responsible for the actions of the Anesthesiologist Assistant.

Under Alabama law, this document is a public record and if requested it will be provided in its entirety.

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.

SUPPLEMENTAL CERTIFICATE TO APPLICATION

FOR REGISTRATION AS AN ANESTHESIOLOGIST ASSISTANT

To:                                                                        (Name and Address of Hospital or Corporate Employer)

The State Board of Medical Examiners has been presented with an

application from                                    for registration as

an anesthesiologist assistant to

M.D.  Information available to the Board indicates that

, M. D., is an employee of

(legal entity), and that

, Anesthesiologist Assistant, is an employee of                                             (legal entity).

To assist the Board in evaluating this application, it is requested that this questionnaire be filled out and executed by the President, Chairman, Chief Executive Officer or Chief Administrative Officer of the corporation or other legal entity that employs the anesthesiologist and the anesthesiologist assistant.  These questions relate directly to the supervisory relationship contemplated by Board Rules, Chapter 540‑X‑7.  When an additional explanation is to be provided, please attach additional information on separate pages.

1. 1. Is the anesthesiologist whose name appears above, employed by you to engage in the full‑time practice of anesthesiology?  If the answer to this question is no, please provide the Board with details of the employment agreement between your corporation and the anesthesiologist.
2. 2. Does the anesthesiologist whose name is stated above have the unqualified authority to terminate the employment of the anesthesiologist assistant registered to him/her?  If the answer to this question is no, please set out in detail the steps required to terminate the employment of the anesthesiologist assistant and identify the officer or officers of the corporation authorized to make that decision.
3. 3. Does the anesthesiologist whose name is stated above, have the unqualified authority to determine the levels of compensation to be paid to the anesthesiologist assistant registered to him/her?  If the answer to this question is no, please set forth in detail the manner in which the compensation of the anesthesiologist assistant is established and the identification of the officer or officers of the corporation who are authorized to establish increase or reduce the compensation of the anesthesiologist assistant.
4. 4. Does the anesthesiologist whose name appears above have the unqualified authority in matters relating to patient care to enforce compliance with orders and directives issued to the anesthesiologist assistant?  Please describe in detail the manner in which such orders and directives may be enforced.
5. 5. Is the anesthesiologist assistant whose name appears above subject to the supervision, direction or control of any officer, director, supervisor or employee of the corporation other than the anesthesiologist to whom he or she is registered?  If the answer to this question is yes, please explain in detail, identifying the individual exercising the supervision, direction or control and the circumstances in which such supervision, direction and control would be exercised.
6. 6. In matters relating to patient care, is the anesthesiologist assistant whose name appears above subject to the immediate supervision, direction or control of any non‑physician?  If yes, explain the relationship.

7. 7. Will the anesthesiologist assistant whose name appears above be expected or required to perform any part of his or her duties at any time when the anesthesiologist to whom he or she is registered is not on duty and physically present on the premises of the hospital, clinic, or facility where the anesthesiologist assistant services will be rendered?  If the answer to this question is yes, please explain in detail all such circumstances.

   I understand that the information submitted herein is to be used by the Board of Medical Examiners as the basis for certification of an anesthesiologist assistant and that the furnishing of false or misleading information or the future occurrence of substantial departures from or violations of the standards and procedures outlined in this response, may be considered by the Board as grounds for termination of the certification of the anesthesiologist assistant.

   The undersigned hereby certifies that the foregoing information is true and correct to the best of my knowledge, information and belief.

   Name of the Corporation                           Title of Officer Signing Certificate

   Printed Name of the Officers Signing Certificate                             Signature

   This form should be completed, printed, and provided directly to the Alabama Board of Medical Examiners.  Facsimile and email of this form are accepted.

Author: Alabama State Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§34-24-293, 34-24-3-298, 34-24-299, 34-24-303. 34-24-306.

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

History: Repealed and Replaced: Filed September 21,1998; effective October 26, 1998. Amended: Filed July 23, 1999; effective August 27, 1999. Repealed and New Appendix: Filed September 19, 2002; effective October 24, 2002. Repealed and New Appendix: Filed February 27, 2018; effective April 14, 2018. Amended: Filed August 22, 2018; effective October 6, 2018.