ALABAMA BOARD OF MEDICAL EXAMINERS

Appendix E

Physician Assistant/Anesthesiologist Assistant License Renewal

20XX Physician Assistant/Anesthesiologist Assistant License Renewal

Deadline: December 31, 20XX

Failure to apply for license renewal and pay renewal fee will result in the license automatically being placed in an inactive status, making it illegal for the holder to practice as a Physician Assistant/Anesthesiologist Assistant effective January 1, 20XX.

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

CME Certification: (Select One)

I hereby certify that I have met or will meet by December 31 the minimum continuing education requirement of 50 AMA PRA Category I Credits™ or equivalent continuing medical education earned within the immediately preceding two calendar years and have or will have supporting documentation if audited.

I hereby certify that I am exempt from the minimum continuing medical education requirement for the following reason (Select One)

I received my initial license to practice in Alabama in the calendar year 20XX.

I am exempt from the CME requirement for the calendar year 20XX because I am a member of a branch of the armed services and I was deployed for military service in the calendar year 20XX.

I have obtained a waiver from the Board of Medical Examiners due to illness, disability or other hardship condition which existed in the calendar year 20XX.

National Commission on Certification of Physician Assistants (NCCPA):

Are you currently certified by NCCPA?

If your answer is “yes”, provide your certification number and certification expiration date.

National Commission for Certification of Anesthesiologist Assistants (NCCAA):

Are you currently certified by NCCAA?

If your answer is “yes”, provide your certification number and certification expiration date.

Professional Responsibility Certification

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

Legal:

1. 1.   Since your last renewal, have you 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.   Since your last renewal, have you 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.    Since your last renewal, have you 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.    Since your last renewal, 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.  Since your last renewal, have you 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.    Since your last renewal, have you 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?
7. 7.   Since your last renewal, has your certification or license to practice as an assistant to physicians in any state or jurisdiction been subject to any discipline, including but not limited to revocation, suspension, probation, restrictions, conditions, reprimand, or fine?
8. 8.    Since your last renewal, have your privileges at any hospital or health care facility been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?

9. 9.    To your knowledge, as of the date of this application and since your last renewal, 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 two 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, 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]

    Practice Interruption:

13. 13.    Since your last renewal, has your professional education, training, or 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?

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?

    Review the following Registration Agreements (RA) (If any):

    Is this Registration Agreement still Active?

    How many hours per week do you work under this Registration Agreement?

    Please provide a date of termination

    What was the reason this Registration Agreement was terminated

    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 could result in disciplinary action.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §34-24-299.

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

History: Amended: Published January 31, 2024; effective March 16, 2024. New Appendix: Filed July 23, 1999; effective August 27, 1999. Repealed and New Appendices: Filed September 19, 2002; effective October 24, 2002. Amended: Filed February 17, 2012; effective March 23, 2012. Amended: (Appendix C was repealed and original Appendix E was renamed Appendix C; Appendix I was renamed Appendix E) Filed February 27, 2018; effective April 14, 2018. Amended: Published December 30, 2022; effective February 13, 2023. Amended: Published March 31, 2025; effective May 15, 2025.