Alabama Administrative Code Chapter 545-X-A — Appendices

545 Medical Licensure Commission of Alabama

Ala. Admin. Code r. 545-X-A-A-Ch-2 Application For License To Practice Medicine (Repealed 8/14/12)

Appendix A/Ch. 2

APPLICATION FOR LICENSE TO PRACTICE MEDICINE

(Repealed 8/14/21)

History

• Authority: Code of Ala. 1975,
• Amended: Filed July 23, 1997; effective August 27, 1997. Amended: Filed March 4, 2003; effective April 8, 2003. Amended: Filed May 5, 2010; effective June 9, 2010. Amended: Filed January 11, 2019; effective February 25, 2019. Repealed: Published June 30, 2021; effective August 14, 2021.

Ala. Admin. Code r. 545-X-A-B-Ch-2 20XX Alabama Medical License Renewal Application

Appendix B/Chapter 2

20XX Alabama Medical License Renewal Application

Deadline: December 31, 20XX

Failure to renew this license by January 31 will result in license becoming inactive without further notice.

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

CME Certification: (Select One)

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.

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

I do not reside in the State of Alabama and do not have a significant portion of my medical practice in the State of Alabama

I was exempt from the CME requirement for the previous calendar year 20XX, and I moved my residence to the State of Alabama during the calendar year 20XX.

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

I have obtained a retirement waiver from the Board of Medical Examiners, and I do not engage in the practice of medicine in any form.

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.

I am enrolled or was enrolled in a residency training program or clinical fellowship program during 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.

Practice Information

1. Are you actively engaged in clinical practice in the State of Alabama? Yes No

2. What type of specialty area do you practice?

3. Do you currently perform/offer to perform any office based surgery/procedure which requires 1) moderate sedation, deep sedation, or general anesthesia; 2) liposuction when infiltration methods such as the tumescent technique are used; or 3) any procedure in which Propofol is administered, given or used? Remember: Office-based surgery is surgery* performed outside a hospital or outpatient facility licensed by the Alabama Department of Public Health.

*Definition of Surgery: Surgery, which involves the revision, destruction, incision or structural alteration of human tissue performed, using a variety of methods and instruments, is a discipline that includes the operative and non-operative care of individuals in need of such intervention, and demands pre-operative assessment, judgement, technical skills, post-operative management and follow­ up.

Primary Care Information

4. Does your practice included the delivery of primary care or mental health services, defined as basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system, exclusive of an emergency situation? It does NOT include administrative, hospitalists, research, teaching, inpatient, emergency/urgent care, or specialized care.)

5. What is your National Provider Identifier (NPI) Number?

6. Do you work for the military, Veterans Administration, or a federal/state correctional facility?

7. Are you planning to retire in the next 12 months?

8. Are you an intern or resident?

9. What are your practice addresses? (Please include street, city, county, and zip code for each address)

10. How many hours per week do you provide direct patient care? (Do NOT include on call, hospital or nursing home rounds, drug rehab centers, jail, emergency room shifts, or similar sites.)

11. What percentage of the total patient base is on Medicaid? (If none, enter zero)

12. Is a formal sliding fee sale used, based on the patient's income or ability to pay? (Must be available to all uninsured patients.)

NOTE: Repeat questions 9 through 12 for each practice location.

Professional Responsibility Certification

SINCE YOUR LAST RENEWAL:

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. 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. 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. 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. 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. 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. 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 (If yes, please include a detailed explanation)

8. 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 (If yes, please include a detailed explanation)

9. Have you been charged, investigated, sanctioned, or have there been any complaints filed against you, relating to sexual boundary issues? Yes No (If yes, please include a detailed explanation)

10. 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.weebfv.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.

11. 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.

History

• Author: Alabama Medical Licensure Board
• Authority: Code of Ala. 1975, §34-24-337.
• Amended: Filed July 23, 1997; effective August 27, 1997. Amended: Filed March 4, 2003; effective April 8, 2003. Amended: Filed April 23, 2004; effective May 28, 2004. Repealed and New Rule: Filed February 27, 2006; effective April 3, 2006. Amended: Filed July 26, 2007; effective August 30, 2007. Amended: Filed November 30, 2007; effective January 4, 2008. Amended: Filed May 5, 2010; effective June 9, 2010. Amended: Filed June 6, 2012; effective July 11, 2012. Amended: Filed August 30, 2012; effective October 4, 2012. Amended: Filed January 15, 2013; effective February 19, 2013. Amended: Filed June 5, 2013; effective July 10, 2013. Amended: Filed November 26, 2014; effective December 31, 2014. Repealed and New Rule: Filed January 5, 2018; effective February 19, 2018. Amended: Filed January 11, 2019; effective February 25, 2019. Amended: Published December 30, 2021; effective February 13, 2022. Amended: Published December 31, 2025; effective February 14, 2026.

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:

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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):

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). If yes, please include a detailed explanation.

_____ Yes _____ No

1. 1. 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

1. 1. 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

1. 1. Have you been denied a state or federal controlled substances certificate? If yes, please include a detailed explanation. _____ Yes _____ No
2. 1. 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 2. 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 3. 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
3. 1. 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
4. 1. 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
5. 1. 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
6. 1. 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 2. Have you been charged, investigated, sanctioned, or have there been any complaints filed against you, relating to sexual boundary issues?

_____ Yes _____ No

1. 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.

1. 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.

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Physician Signature

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

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Notary Signature

My Commission Expires: _____________________

History

• Author: Alabama Medical Licensure Commission
• Authority: Code of Ala. 1975,
• 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.

Ala. Admin. Code r. 545-X-A-D-Ch-2 Retired Senior Volunteer Program: Application For Limited License To Practice Medicine (Repealed 8/14/12)

Appendix D/Chapter 2

RETIRED SENIOR VOLUNTEER PROGRAM

APPLICATION FOR LIMITED LICENSE TO PRACTICE MEDICINE

(Repealed 8/14/21)

History

• Author: Alabama Medical Licensure Commission
• Authority: Code of Ala. 1975,
• New Form: Filed September 27, 2004; effective November 1, 2004. Amended: Filed January 11, 2019; effective February 25, 2019. Amended: Published June 30, 2021; effective August 14, 2021.

Ala. Admin. Code r. 545-X-A-E-Ch-2 20XX Retired Senior Volunteer Program Medical License Renewal Application

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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

History

• Author: Alabama Medical Licensure Commission
• Authority: Code of Ala. 1975,
• 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.

Ala. Admin. Code r. 545-X-A-A-Ch-4 Application For Reinstatement Of License (Repealed 12/30/03)

Appendix A/Chapter 4

Application For Reinstatement Of License

(Repealed 12/30/03)

History

• Author: Alabama Medical Licensure Commission
• Authority: Code of Ala. 1975,
• Repealed: Filed November 25, 2003; effective December 30, 2003.

Ala. Admin. Code r. 545-X-A-A-Ch-6 Application For A Special Purpose License To Practice Medicine/ Osteopathy (Repealed 8/14/12)

Appendix A/Chapter 6

APPLICATION FOR A SPECIAL PURPOSE LICENSE TO PRACTICE MEDICINE/OSTEOPATHY

(Repealed 8/14/21)

Ala. Admin. Code r. 545-X-A-B-Ch-6 Application For Renewal Of A Special Purpose License

Appendix B/Chapter 6

History

• Author: Alabama Medical Licensure Commission
• Authority: Code of Ala. 1975,
• New Form (App. A & B): Filed February 25, 2005; effective April 1, 2005. Amended: Filed July 26, 2007; effective August 30, 2007. Amended: Filed January 15, 2013; effective February 19, 2013. Amended: Filed December 1, 2015; effective January 5, 2016. Repealed and New Rule: Filed January 5, 2018; effective February 19, 2018. Amended (App. A only): Filed January 11, 2019; effective February 25, 2019. Repealed (Appendix A): Published June 30, 2021; effective August 14, 2021.

Ala. Admin. Code r. 545-X-A-Opinion Re: Social Security Numbers – Public Records