Ala. Admin. Code r. 540-X-7-Appendix-F

Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License

Effective May 15, 2025Repealed and Replaced (Entire Appendices for Chapter 7): Filed September 21, 1998; effective October 26, 1998. Amended (Appendices A D for Chapter is amended Appendices E J is new): Filed July 23, 1999; effective August 27, 1999. Repealed and New Appendices (A J): Filed September 19, 2002; effective October 24, 2002. Amended (Appendices I & J only): Filed May 21, 2004; effective June 25, 2004. Amended (Appendices B & F only): Filed November 19, 2004; effective December 24, 2004. Amended: Filed April 13, 2006; effective May 18, 2006. Amended (Appendix A only): Filed April 17, 2008; effective May 22, 2008. Amended (Added New Appendix K only): Filed October 15, 2008; effective November 19, 2008. Amended (Appendix B only): Filed December 18, 2008; effective January 22, 2009. Amended (Appendix I only): Filed July 16, 2009; effective August 20, 2009. Repealed (Appendix J only): Filed August 5, 2009; effective September 9, 2009. Amended (Appendix I only): Filed November 18, 2009; effective December 23, 2009. Amended: Filed March 11, 2010; effective April 15, 2010. Amended (Appendix B only): Filed May 20, 2010; effective June 24, 2010. Amended (Appendix I only): Filed October 21, 2010; effective November 25, 2010. Amended (Appendix B only): Filed December 16, 2010; effective January 20, 2011. Amended (Appendices A, D, E, H, and K only): Filed February 17, 2012; effective March 23, 2012. Amended (Appendices D and H only): Filed August 16, 2012; effective September 23, 2012. Amended (Appendices D and H only): Filed July 22, 2013; effective August 26, 2013. Amended (Appendices D, H, I and K only): Filed March 20, 2014; effective April 24, 2014. Amended (Appendix F only): Filed July 21, 2016; effective September 4, 2016. Repealed and New Rule (Appendix I only): Filed July 20, 2017; effective September 3, 2017. Amended (Appendix A only): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix B was repealed and Appendix D was renamed Appendix B): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix C was repealed and Appendix E was renamed Appendix C): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix D was repealed and Appendix H was renamed Appendix D): Filed February 27, 2018; effective April 14, 2018. Amended (Appendix I was renamed Appendix D): Filed February 27, 2018; effective April 14, 2018. Repealed (Appendix F only): Filed February 27, 2018; effective April 14, 2018. Amended (Appendix K was renamed Appendix F): Filed February 27, 2018; effective April 14, 2018. Repealed (Appendix G only): Filed February 27, 2018; effective April 14, 2018. Amended (Appendices A D only): Filed August 22, 2018; effective October 6, 2018. Amended (Appendix A only): Published November 30, 2020; effective January 14, 2021. Amended (Appendices B and D only): Published March 31, 2021; effective May 15, 2021. Amended (Appendix A only): Published October 29, 2021; effective December 13, 2021. Amended (Appendices B, D & E only): Published December 30, 2022; effective February 13, 2023. Amended (Appendix F): Published January 31, 2023; effective March 17, 2023. Amended: Published March 31, 2025; effective May 15, 2025.Alabama Board of Medical Examiners

ALABAMA BOARD OF MEDICAL EXAMINERS

Appendix F

APPLICATION FOR REINSTATEMENT OF

Physician Assistant/Anesthesiologist Assistant License

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

APPLICATION FOR REINSTATEMENT OF

PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE

NAME

ADDRESS

INITIAL LICENSE NUMBER

ISSUE DATE

DATE OF REVOCATION/SUSPENSION/SURRENDER OF LICENSE:

REASONS FOR REVOCATION/SUSPENSION/VOLUNTARY SURRENDER OF LICENSE (Please give detailed reasons)

Required background information:

If your answer is "yes," please provide a detailed explanation in the space provided.

Legal:

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?
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. 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. 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. Have you ever been denied prescription privileges for non-controlled or legend drugs by any state or federal authority?
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. 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. Have your privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?
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. 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. 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:
13. 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?
14. Are you currently registered, certified to or working for any other primary supervising physician/anesthesiologist in another state? ie, are you presently working as a physician/anesthesiologist assistant? If so, answer yes.
If YES, list the name and principal practice location of each primary supervising physician/anesthesiologist to whom you are certified. In addition, state your designated working hours per week for each physician/anesthesiologist listed.
15. Have you ever been certified as a physician/anesthesiologist assistant by the Alabama Board of Medical Examiners in the past?
If YES, please list the names of the physicians/anesthesiologists.
Please list all states in which you hold or have applied for licensure:
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, 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.
Assistant to Physicians’ Signature

Author: Alabama State Board of Medical Examiners

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

History: Repealed and Replaced (Entire Appendices for Chapter 7): Filed September 21, 1998; effective October 26, 1998. Amended (Appendices A D for Chapter is amended Appendices E J is new): Filed July 23, 1999; effective August 27, 1999. Repealed and New Appendices (A J): Filed September 19, 2002; effective October 24, 2002. Amended (Appendices I & J only): Filed May 21, 2004; effective June 25, 2004. Amended (Appendices B & F only): Filed November 19, 2004; effective December 24, 2004. Amended: Filed April 13, 2006; effective May 18, 2006. Amended (Appendix A only): Filed April 17, 2008; effective May 22, 2008. Amended (Added New Appendix K only): Filed October 15, 2008; effective November 19, 2008. Amended (Appendix B only): Filed December 18, 2008; effective January 22, 2009. Amended (Appendix I only): Filed July 16, 2009; effective August 20, 2009. Repealed (Appendix J only): Filed August 5, 2009; effective September 9, 2009. Amended (Appendix I only): Filed November 18, 2009; effective December 23, 2009. Amended: Filed March 11, 2010; effective April 15, 2010. Amended (Appendix B only): Filed May 20, 2010; effective June 24, 2010. Amended (Appendix I only): Filed October 21, 2010; effective November 25, 2010. Amended (Appendix B only): Filed December 16, 2010; effective January 20, 2011. Amended (Appendices A, D, E, H, and K only): Filed February 17, 2012; effective March 23, 2012. Amended (Appendices D and H only): Filed August 16, 2012; effective September 23, 2012. Amended (Appendices D and H only): Filed July 22, 2013; effective August 26, 2013. Amended (Appendices D, H, I and K only): Filed March 20, 2014; effective April 24, 2014. Amended (Appendix F only): Filed July 21, 2016; effective September 4, 2016. Repealed and New Rule (Appendix I only): Filed July 20, 2017; effective September 3, 2017. Amended (Appendix A only): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix B was repealed and Appendix D was renamed Appendix B): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix C was repealed and Appendix E was renamed Appendix C): Filed February 27, 2018; effective April 14, 2018. Repealed and New Rule (Appendix D was repealed and Appendix H was renamed Appendix D): Filed February 27, 2018; effective April 14, 2018. Amended (Appendix I was renamed Appendix D): Filed February 27, 2018; effective April 14, 2018. Repealed (Appendix F only): Filed February 27, 2018; effective April 14, 2018. Amended (Appendix K was renamed Appendix F): Filed February 27, 2018; effective April 14, 2018. Repealed (Appendix G only): Filed February 27, 2018; effective April 14, 2018. Amended (Appendices A D only): Filed August 22, 2018; effective October 6, 2018. Amended (Appendix A only): Published November 30, 2020; effective January 14, 2021. Amended (Appendices B and D only): Published March 31, 2021; effective May 15, 2021. Amended (Appendix A only): Published October 29, 2021; effective December 13, 2021. Amended (Appendices B, D & E only): Published December 30, 2022; effective February 13, 2023. Amended (Appendix F): Published January 31, 2023; effective March 17, 2023. Amended: Published March 31, 2025; effective May 15, 2025.