Ala. Admin. Code r. 545-X-A-C-Ch-2 – Application For Reinstatement

Appendix C/Chapter 2

APPLICATION FOR REINSTATEMENT

LICENSE NUMBER (IF KNOWN):

NAME IN FULL:

(Last Name) (First Name) (Middle Name)

HOME ADDRESS:

CITY: STATE: ZIP:

COUNTY: HOME TELEPHONE:

HOME E-MAIL ADDRESS:

ARE YOU CURRENTLY IN ACTIVE CLINICAL PRACTICE IN ANY STATE?

___Yes ___ No

TYPE OF PRACTICE:

PRACTICE ADDRESS:

CITY: STATE: ZIP:

PRACTICE TELEPHONE:

PRACTICE E-MAIL ADDRESS:

Please specify the following:

Public Address: _____ Home Address _____ Practice Address

Mailing Address: _____ Home Address _____ Practice Address

Reinstatement & Criminal Background Check Fee $

MAKE CHECKS PAYABLE TO: MEDICAL LICENSURE COMMISSION OF ALABAMA or PAY ONLINE AT ALBME.GOV.

**ALL ACTIVE LICENSES EXPIRE DECEMBER 31 OF EACH YEAR**

Date of Birth: ___________________

Current Practice Information:

Specialty: ___________________________________________________________

Board Certified: _____ Yes _____ No

Name of Board (If yes above): ________________________________________

Date of Certification and/or Re-Certification (If yes above): ________

Other states or jurisdictions in which you are currently licensed:

______________________________________________________________________

______________________________________________________________________

CERTIFICATION OF CME COMPLIANCE

_____ I hereby certify that I have met the annual minimum continuing medical education requirement of twenty-five (25) AMA PRA Category 1 Credits or equivalent continuing medical education within the preceding twelve (12) months.

SINCE YOUR LICENSE WAS LAST ACTIVE IN ALABAMA (Unless otherwise indicated):

Have you been charged with any criminal offense (felony or misdemeanor)? (This includes driving under the influence (DUI), even if you were convicted of a lesser offense). If yes, please include a detailed explanation.

_____ Yes _____ No

Have you been convicted of a crime of offense (felony or misdemeanor) in the practice of medicine? If yes, please include a detailed explanation.

_____ Yes _____ No

Have you been convicted of any violation of state or federal law relating to controlled substances? If yes, please include a detailed explanation.

_____ Yes _____ No

Have you been denied a state or federal controlled substances certificate? If yes, please include a detailed explanation.
_____ Yes _____ No

Has your certificate of qualification or license to practice medicine in any state been suspended, revoked, restricted, curtailed, voluntarily surrendered, or disciplined in any manor? If yes, please include a detailed explanation.
_____ Yes _____ No

Have your staff privileges at any hospital or healthcare facility been revoked, suspended, curtailed, limited, restricted, or voluntarily surrendered? If yes, please include a detailed explanation.
_____ Yes _____ No

Have you been denied a certificate of qualification or a license to practice medicine in any state, or has your application for a certificate of qualification or license to practice medicine been withdrawn under threat of denial? If yes, please include a detailed explanation.
_____ Yes _____ No

Have you had a judgement rendered against you, or an action settled relating to the performance of your professional service? If yes, please include a detailed explanation.
_____ Yes _____ No

Are you the subject of an investigation, or has a formal complaint been filed against you or your license by any licensing board, state or federal, regulatory or law enforcement agency? If yes, please include a detailed explanation.
_____ Yes _____ No

Are you currently engaged in the excessive use of alcohol, controlled substances, or the illegal use of drugs? (“Currently” means sufficiently recently to justify a reasonable belief that the use of the substance may have an ongoing impact on one’s ability to practice medicine with reasonable skill and safety to patients. It is not limited to the day of, or within a matter of days or weeks before the date of this application. Rather, it means that it has occurred recently enough to indicate the individual is actively engaged in such conduct. “Illegal use of drugs” refers to drugs whose possession or distribution is regulated by the Controlled Substances Act. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.)
_____ Yes _____ No

Have you received any therapy or treatment for alcohol or drug use? If you are a participant in the Alabama Professionals Health Program (“APHP”) and are in compliance with your contract, you may answer “No” to this question, and such answer for this purpose will not be deemed upon certification as providing false information to the Alabama Board of Medical Examiners or the Medical Licensure Commission of Alabama. If yes, please provide details.
_____ Yes _____ No

Have you been charged, investigated, sanctioned, or have there been any complaints filed against you, relating to sexual boundary issues?

_____ Yes _____ No

IMPORTANT: The Commission recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other healthcare providers do. The Commission expects its licensees to address their health concerns and ensure patient safety. Options include anonymously self-referring to the Alabama Physician Health Program (www.alabamaphp.weebly.com), 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 Commission taking action against the license to practice medicine.

Please initial certifying that you understand and acknowledge your duty as a licensee to address any such condition as stated above.

Has your medical training or medical practice been interrupted or suspended for a period longer than 60 days for any reason other than vacation, maternity leave, or retirement? If yes, please include a detailed explanation.
_____ Yes _____ No

RELEASE/CERTIFICATION:

I understand and agree that by signing my name, 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.

I understand that the information contained herein may be subject to public inspection or disclosure, and I hereby release the Alabama Medical Licensure Commission and the Alabama Board of Medical Examiners from any and all claims or liability associated with the use or dissemination of the information contained herein.

_____________________________________
Physician Signature

SWORN to and subscribed before me this ____ day of _________________________, 20___.

__________________________________________
Notary Signature

My Commission Expires: _____________________

Author: Alabama Medical Licensure Commission

Statutory Authority: Code of Ala. 1975,

History: New Forms: Filed November 25, 2003; effective December 30, 2003. Amended: Filed April 23, 2004; effective May 28, 2004. Amended: Filed February 27, 2006; effective April 3, 2006. Amended: Filed November 30, 2007; effective January 4, 2008. Amended: Filed October 29, 2008; effective December 3, 2008. Amended: Filed April 5, 2011; effective May 10, 2011. Amended: Filed January 11, 2019; effective February 25, 2019. Repealed and New Rule: Published July 29, 2022; effective September 12, 2022. Amended: Published December 31, 2025; effective February 14, 2026.