Physician assistant registration termination request form

* indicates a required field

Physician's information

Physician's name: *

License number: *

Physician's practice address

Street address: *

Additional address:

City: *

State: *

Zip code: *

PA information

PA's name: *

License number: *

PA's practice address

Street address: *

Additional address:

City: *

State: *

Zip code: *

PA ceased providing services under the registration agreement on

Date (mm/dd/yyyy): *

Reason for termination: *

By entering your name and clicking the submit button I certify that the physician has read and understands the Alabama Board of Medical Examiners Rule 540-X-7-.20 regarding termination. I also understand that failure to adhere to the rules may result in an action against my license.

Submitting person's name: *

Your email address: *

Confirm your email address: *