Collaborative practice termination request form

* indicates a required field

Physician's information

Physician's name: *

License number: *

Street address: *

Additional address:

City: *

State: *

Zip code: *

CRNP/CNM information

CRNP/CNM name: *

License number: *

Street address: *

Additional address:

City: *

State: *

Zip code: *

CRNP/CNM ceased providing services under the collaborative practice agreement on

Date (mm/dd/yyyy): *

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-8-.04 (4) (b) 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: *

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