Forms
PA
Additional Application for Qualified Alabama Controlled Substances Certificate (QACSC)-PA - HAVE had a QACSC
Covering Physician
Letter
Application for Limited Purpose Schedule II Permit (LPSP)-CRNP/CNM/PA
Temporary emergency physician license - COVID-19 health emergency
The forms found throughout this site available for download are listed here for convenience:
Initial physician license applications
Physician assistant license/registration applications
Controlled substances certificates registrations
Laser/other modalities affecting human tissue
Retired senior volunteer program
Continuing medical education web page
Address and name change web page
- update address
- Log into the Licensee Portal to make address changes - Licensee Portal
- Once logged into the Licensee Portal click on the "Update Address" button in the top right corner of the "Address Information" section.
- Follow the prompts to make the necessary address changes.
- Once the address changes have been made you will be returned to the main screen of the Licensee Portal.
- To print a copy of your license or registration scroll to the "License Information" section and click on the printer icon under the "Certificate" column to the right of the license.
- name change request
Physician license applications web page
- application for RSVP certificate of qualification
- certification of free medical clinic
- application for RSVP license (Jan-July) and ACSC
- application for RSVP license (Aug-Dec) and ACSC
- initial application for special purpose certificate of qualification
- initial application for special purpose license (Jan-July) and ACSC
- initial application for special purpose license (Aug-Dec) and ACSC
- initial application for limited certificate of qualification
- application for renewal of limited certificate of qualification
- application for limited license and ACSC (Jan-July) and ACSC
- application for limited license (Aug-Dec) and ACSC
Physician assistant license/registration applications web page
- license application form
- verification of other state licenses/registrations
- 45 day FTE transitional allowance request form
- termination of registration form (must download to computer to use email button)
- P.A. affidavit and release
- A.A. affidavit and release
Registration Agreement Packet:
- application for registration of P.A.
- Core Duties and Scope of Practice
- supplemental certificate of hospital/employer - if applicable
- formulary for non-controlled prescribing - if applicable
- covering physician agreement - if applicable
Additional skills request:
- skill protocol template
- critical care skill requirements for initial certification
- critical skills request to train
- orthopedic specialty protocol
- orthopedic specialty protocol request to train
- otolaryngology specialty protocol
- otolaryngology specialty protocol request to train
- botulinum toxin for hyperhidrosis protocol
- botulinum toxin for hyperhidrosis protocol request to train
Controlled substances certificates applications web page
- Alabama Controlled Substances Certificate applications must be requested - see controlled substances certificates information page
- CRNP/CNM
- Initial Application for Qualified Alabama Controlled Substances Certificate (QACSC)-CRNP/CNM - NEVER had a QACSC
- Additional Application for Qualified Alabama Controlled Substances Certificate (QACSC)-CRNP/CNM - HAVE had a QACSC
- Covering Physician Letter
- Initial Application for Qualified Alabama Controlled Substances Certificate (QACSC)-PA - NEVER had a QACSC
Office based surgery web page
- registration form (registration is online only)
- adverse event reporting form
Laser/other modalities web page
Pain Management Services web page
- registration application
- registration renewal will be accomplished online
Collaborative practices web page
- Collaborative Practice commencement instructions and form
- Collaborative Practice online termination process
- Notice of termination
- 45-day transitional allowance request
- Procedure protocol template
- Joint injection request
- Orthopedic skills grid
- Otolaryngology Procedures Request Form
- Statewide criteria for otolaryngology procedures
- Critical care skills request form
- Critical care skill requirements for initial certification
- Critical care advanced protocol initial requirements attestation
- Critical care advanced protocol ATS designation criteria attestation
- Advanced protocol training record
- CVL advanced request to train
- Chest tube request to train
- Thoracentesis request to train
- Request for additional skills outside of protocol
Retired Senior Volunteer Program web page
- application for replacement of lost or destroyed wall certificate web page
- malpractice payment report form for insurance companies web page
- dispensing physician registration form web page
- inactive license reinstatement form web page
- request active-non renewal status web page
- request written license verification web page
- request duplicate annual renewal certificates web page
- declaration of citizenship and lawful presence of an alien web page
- other state license verification request
Copyright 2018 © The Alabama Board of Medical Examiners
All rights reserved
All rights reserved