Appendix E/Chapter 2

20XX Retired Senior Volunteer Program Medical

License Renewal Application

Deadline: December 31, 20XX

Failure to renew this license by December 31 will result in license becoming inactive without further notice under the restrictions of the Retired Senior Volunteer Program.

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

CME Certification:

I hereby certify that I have met or will meet by December 31 the annual minimum continuing education requirement of 25 AMAPRA Category I Credits TM or equivalent continuing medical education for the calendar year 20XX and have or will have supporting documentation if audited.

Professional Responsibility Certification

SINCE YOUR LAST RENEWAL:

1. 1.   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)? Yes  No   (If yes, please include a detailed explanation)
2. 2.   Has your certificate of qualification or license to practice medicine or osteopathy in any state been suspended, revoked, restricted, curtailed, voluntarily surrendered, or disciplined in any manner?   Yes    No  (If yes, please include a detailed explanation)
3. 3.   Have your staff privileges at any hospital or health care facility been revoked, suspended, curtailed, limited, restricted or voluntarily surrendered?   Yes  No   (If yes, please include a detailed explanation)

4. 4.   Have you been denied a certificate of qualification or a license to practice medicine or osteopathy in any state or has your application for a certificate of qualification or license to practice medicine or osteopathy been withdrawn under threat of denial?   Yes

   No   (If yes, please include a detailed explanation)

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

6. 6.   Are you the subject of an investigation, or has a formal complaint been filed against you or your license by any licensing board or state, federal, regulatory or law enforcement agency? Yes

   No   (If yes, please include a detailed explanation)

7. 7.   Have you engaged in the excessive use of alcohol, controlled substances, or the use of illegal drugs, or received any therapy or treatment for alcohol or drug use or sexual boundary issues? (If you are a participant in the Alabama Physician Health Program and are in compliance with your contract, you may answer "No" to this question, 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).   Yes     No     If you answer "yes", then a description is required.

8. 8.   Important:  The Commission recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other health care 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.

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

   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.

Author: Alabama Medical Licensure Commission

Statutory Authority: Code of Ala. 1975,

History: New Form: Filed September 27, 2004; effective November 1, 2004. Repealed and New Rule: Filed February 27, 2006; effective April 3, 2006. Amended: Filed May 5, 2010; effective June 9, 2010. Amended: Filed January 15, 2013; effective February 19, 2013. Amended: Filed November 26, 2014; effective December 31, 2014. Amended: Filed December 1, 2015; effective January 5, 2016. Repealed and New Rule: Filed January 5, 2018; effective February 19, 2018. Amended: Published December 30, 2021; effective February 13, 2022.