ALABAMA BOARD OF MEDICAL EXAMINERS

Appendix D

APPLICATION FOR LICENSURE OF ANESTHESIOLOGIST ASSISTANT

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

Required demographic information:

Name in full (First. Middle, Last, M.D./D.O.)

Alternate name(s) used

Address (Street, City, State, Zip)

Email address

Place of birth

Date of birth

Social Security Number (Pursuant to Ala. Code §30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued.)

Sex

Telephone (H or C)

Telephone (W)

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 prescription privileges for non-controlled or legend drugs by any state or federal authority?
7. 7.    Have you ever been denied a license to practice as an assistant to physicians in any state or jurisdiction or has your application for a license to practice as an assistant to physicians been withdrawn under threat of denial?
8. 8.    Has your certification or license to practice as an assistant to physicians in any state or jurisdiction ever been subject to any discipline, including but not limited to revocation, suspension, probation, restrictions, conditions, reprimand, or fine?
9. 9.    Have your privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?

10. 10.   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:

11. 11.  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?
12. 12.   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?

13. 13.  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, an 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 as an assistant to physicians.

    I have read and understand the statements above.

    [Applicant Attestation]

    Education/Training/Experience:

14. 14.    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?

15. 15.   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?

    When entering attendance dates below, you may use the first date of the month instead of the exact date. (Ex: attended August 1990 - July 1994, enter 08/01/1990 - 07/01/1994)

    Education (beginning with undergraduate degree)

    Upload a copy of your diploma(s) reflecting graduation from an Anesthesiologist

    Assistant Program

    School Name Start Date End Date

    School Address

    Activities Since Beginning Undergraduate Degree (cover all time periods)

    Place of Employment or Activity Start Date

    End Date
    Address

    Examination

    Have you successfully completed the Anesthesiologist Assistant National Certifying Examination?

    If YES, upload verifying documentation from the National Commission on Certification of Anesthesiologist Assistants (NCCAA).

    If NO, have you ever taken the examination?

    Are you registered to take the examination?

    If YES upload verifying documentation from the NCCAA. Test date:

    Current Practice

    Are you currently registered, certified to or working for any other primary supervising physician in another state? i.e., Are you presently working as an anesthesiologist assistant? If so, answer yes.

    If YES, provide the name and principal practice location of each primary supervising physician to whom you are certified. In addition, state your designated working hours per week for each physician listed.

    Certification of Licensure in Other States

    List all states where you have been certified/registered/licensed as an assistant to physicians. Primary source verification is required from any state that does not report anesthesiologist assistant data to the Federation of State Medical Boards.

    Certification and Release:

    I, [full name], certify that all of the information supplied in the submitted application is true and correct to the best of my knowledge, and that the photograph submitted herein is a true likeness of me and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this application may result in the denial of this application or revocation of any certification/licensure granted.

    I further consent to and authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information and release of the Alabama Board of Medical Examiners from all liability for the release of this information.

    I further consent to and authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners and release this person or any organization from any liability for the release of information.

    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.

    Anesthesiologist Assistant's Signature

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 D was repealed and Appendix H was renamed Appendix D 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. Amended: Filed February 17, 2012; effective March 23, 2012. Amended: Filed August 16, 2012; effective September 23, 2012. Amended: Filed July 22, 2013; effective August 26, 2013. Amended: Filed March 20, 2014; effective April 24, 2014. Repealed and New Appendix: Filed February 27, 2018; effective April 14, 2018. Amended: Filed August 22, 2018; effective October 6, 2018. Amended: Published March 31, 2021; effective May 15, 2021. Amended: Published December 30, 2022; effective February 13, 2023. Amended: Published March 31, 2025; effective May 15, 2025.