Ala. Admin. Code ch. 630-X-A | Alabama Administrative Code Chapter 630-X-A — Appendices

630 Alabama Board of Optometry

Ala. Admin. Code r. 630-X-A-1 Complaint Form - 630-X-3-.01

Rule 630-X-3-.01

ALABAMA BOARD OF OPTOMETRY

How To File A Complaint

Any person may file a complaint with the Alabama Board of Optometry.

Complaints against licensed optometrists for unprofessional, unethical, or illegal conduct and complaints against any other person who may be accused of violating any provision of the Alabama Optometry Law can contact the Executive Director in writing and under oath (signed, including the phrase "Sworn to and subscribed before me ..." and notarized).

The Alabama Board of Optometry is responsible for investigating unprofessional, unethical, or illegal acts, and does not pursue consumer complaints. These complaints are directed to consumer rights organizations.

The complaint must set out in detail the charge(s) against the accused person and must contain a telephone number at which the person registering the complaint can be reached by telephone.

Mail the notarized complaint to:

Dr. Fred Wallace Executive Director Alabama Board of Optometry 1431 Second Avenue, North Bessemer, AL 35020

If you have questions about these procedures, you may contact Dr. Wallace at (205) 481-9993 or fred.wallace@optometry.alabama.gov.

You may use the attached Complaint Form. Please include all facts that you feel are important, including date(s), names of all individuals involved, and any information that would assist in our investigation.

All documentation that you attach become the property of the Board and cannot be returned.

The Board will contact you upon receipt of your complaint, may request additional information, and will notify you of its decision concerning the complaint.

Alabama Board of Optometry 1431 Second Avenue, North Bessemer, AL 35020 (205) 481-9993 (205) 481-9959 fax www.optometry.alabama.gov

Complaint Please type or print legibly

Your Name:

Your Home Address:

Your Work Address:

Your Home Phone:

Your Work Phone:

On whom are you filing this complaint (include an address)?

Explain your complaint:

ATTACH ADDITIONAL PAGES IF NECESSARY

Attach photocopies off all supporting documents

Sworn to and subscribed before me on this the _______day of _________, 2.

Ala. Admin. Code r. 630-X-A-2 Election Nomination Form - 630-X-4.02(3) App. A

Rule 630-X-4-.02(3)

For U.S. Congressional District

ELECTION NOMINATION FORM - APPENDIX A

I hereby submit to the Alabama Board of Optometry the following list of names of two optometrists qualified for membership on the Board.

Licensed Optometrist

License Number

STATE OF ALABAMA

_________________ County

I, the undersigned authority, hereby certify that _______________________________, whose name is signed to the foregoing list, and who is known to me, acknowledged before me on this day that, being informed of the contents of the list, he signed the same voluntarily on the day the same bears date.

Given under my hand and seal of office on this

_____________ day of ____________________, ________.

Signature

Ala. Admin. Code r. 630-X-A-3 Election Petition Form - 630-X-4.02(8) App. B

Rule 630-X-4-.02(8)

ELECTION PETITION FORM-APPENDIX B

We herewith submit the name of ___________________________________________________

as a nominee for consideration by this annual meeting.

This ____________ day of ______________________, ________.

Signature - License number

Ala. Admin. Code r. 630-X-A-4 Application For Licensure - 630-X-5-.01

Ala. Admin. Code r. 630-X-A-5 Application For Licensees To Be Certified To Use Pharmaceutical Agents - 630-X-5.08

Rule 630-X-5-.08 Appendix B

PROTOCOL FOR THE THERAPEUTIC USE OF PHARMACEUTICAL AGENTS FOR THE TREATMENT OF DISEASE OF THE EYE AND ITS ADJACENT STRUCTURES

Prior to board approval for the therapeutic use of pharmaceutical agents, this Form must be completed and approved by the board. In the case that the board does not approve your protocol, this form or a copy thereof will be returned to you with the reasons it was not approved. You may then correct the problem areas and reapply.

Name:

Mailing address:

Physical location of each place you practice (use other side if needed):

License number:

Social Security number:

Office telephone number:

Do you have an arrangement whereby your patients and/or emergencies are covered if you are unavailable?

Have all of your staff been instructed in whom to call and how to handle a medical emergency in your office?

Please attach a written copy of these instructions.

Do you have 24 hour access to your office?

If not, please give a brief explanation of arrangements you have made to care for after hours emergencies:

Is there a person in your office (either yourself or a fulltime staff person) who has had CPR training?

Signature/date

Ala. Admin. Code r. 630-X-A-6 Protocol For The Therapeutic Use Of Pharmaceutical Agents For The Treatment Of Disease Of The Eye And Its Adjacent Structures - 630-X-5.08

APPLICATION FOR LICENSEES TO BE CERTIFIED TO USE PHARMACEUTICAL AGENTS

Name:

Addresses of all practice locations (use reverse of page if necessary):

Telephone(s):

Present license number:

Attach to this form the following:

Your check for $110.00 ($100 therapeutic license + $10 to fund the Prescription Drug Monitoring Program as required by Alabama Law).
Proof of attending seventytwo (72) Board approved clock hours in the diagnosis and management of diseases of the human eye and its adjacent structures taken within a three year period preceding this application.
A completely filled out form entitled “PROTOCOL FOR THE THERAPEUTIC USE OF PHARMACEUTICAL AGENTS FOR THE TREATMENT OF DISEASES OF THE EYE AND ITS ADJACENT STRUCTURES.”

Signature of applicant

Ala. Admin. Code r. 630-X-A-7 Record Of Attendance - Form CE-1 - 630-X-7.07 App. A

Rule 630-X-7-.07

CERTIFICATE OF ATTENDANCE APPENDIX A

(FORM CE1)

The_____________________________________________________ hereby Sponsor’s Name certifies

that ____________________________________ OD Name

License No.

Attended the following clock hours of study:

Name of Course:______________________________________________________

Lecturer:______________________________________________________________

Date:_________________________________________________________________

Number of Hours:_______________________________________________

Signature or Certification of Sponsor

Ala. Admin. Code r. 630-X-A-8 Application-Practice Across State Lines - 630-X-13.05

Rule 630-X-13-.05

APPLICATION FOR THE ISSUANCE OF A CERTIFICATE OF QUALIFICATION FOR A SPECIAL PURPOSE LICENSE TO PRACTICE OPTOMETRY ACROSS STATE LINES

Full name of applicant__________________________________________

Residence Address ______________________________________________

City, State and Zip Code________________________________________

Residence Telephone Number______________________________________

License number and name of state in which you currently practice ____________________________

Applicant must do the following:

Have your State Board of Optometry send to the ALABAMA BOARD OF OPTOMETRY evidence that the applicant holds a current, full and unrestricted license to practice optometry and that there are no previous or pending disciplinary action or other action taken against the applicant by any state or other licensing jurisdiction.

Enclose the application fee of $600.00.

By signing this application the applicant affirms his or her intent and willingness to report to the ALABAMA BOARD OF OPTOMETRY in writing the initiation of any disciplinary action against him or her by any state or territory in which he or she is licensed. Said report shall be submitted to the ALABAMA BOARD OF OPTOMETRY within 15 days of the initiation of such disciplinary action.

Signature of Applicant__________________________________________

Date_________________________________________________________________________________

ALABAMA BOARD OF OPTOMETRY 1431 Second Avenue, North Bessemer, AL 35020

(205) 481-9993

Alabama Administrative Code Chapter 630-X-A — Appendices