Phyisician Assistant/Anethesiologist Assistant registration termination request form

* indicates a required field

Physician's information

Physician's practice address

PA/AA information

PA/AA's practice address

PA/AA ceased providing services under the registration agreement on

By entering my 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 the physician's license.


This form uses Huggins' Email Form Script

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