Medical Licensure Commission ALABAMA DEPARTMENT OF MEDICAL LICENSURE COMMISSION ADMINISTRATIVE CODE APPENDICES TABLE OF CONTENTS

Transcription

1 Medical Licensure Commission Appendices ALABAMA DEPARTMENT OF MEDICAL LICENSURE COMMISSION ADMINISTRATIVE CODE APPENDICES TABLE OF CONTENTS Appendix A/Ch. 2 Appendix B/Ch. 2 Appendix C/Ch. 2 Appendix D/Ch. 2 Appendix E/Ch. 2 Appendix A/Ch. 4 Appendix A/Ch. 6 Appendix B/Ch. 6 Application For License To Practice Medicine/Osteopathy License Renewal For 20 Application For Reinstatement Retired Senior Volunteer Program: Application For Restricted License To Practice Medicine of Osteopathy Retired Senior Volunteer Program: Application For Renewal Of License To Practice Medicine Or Osteopathy Application For Reinstatement Of License (Repealed 12/30/03) Application For A Special Purpose License To Practice Medicine/ Osteopathy Application For Renewal Of A Special Purpose License Opinion Re: Social Security Numbers Public Records Supp. 3/31/18 A-0

2 Appendices Medical Licensure Commission Appendix A/Ch. 2 Supp. 3/31/18 A-1

3 Medical Licensure Commission Appendices Author: Statutory Authority: Code of Ala. 1975, History: Amended: Filed July 23, 1997; effective August 27, Amended: Filed March 4, 2003; effective April 8, Amended: Filed May 5, 2010; effective June 9, Supp. 3/31/18 A-2

4 Appendices Medical Licensure Commission Appendix B/Chapter 2 Supp. 3/31/18 A-3

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6 Appendices Medical Licensure Commission m Supp. 3/31/18 A-5

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8 Appendices Medical Licensure Commission Author: Alabama Medical Licensure Board Statutory Authority: Code of Ala. 1975, History: Amended: Filed July 23, 1997; effective August 27, Amended: Filed March 4, 2003; effective April 8, Amended: Filed April 23, 2004; effective May 28, Repealed and New Rule: Filed February 27, 2006; effective April 3, Amended: Filed July 26, 2007; effective August 30, Amended: Filed November 30, 2007; effective January 4, Amended: Filed May 5, 2010; effective June 9, Amended: Filed June 6, 2012; effective July 11, Amended: Filed August 30, 2012; effective October 4, Amended: Filed January 15, 2013; effective February 19, Amended: Filed June 5, 2013; effective July 10, Amended: Filed November 26, 2014; effective December 31, Repealed and New Rule: Filed January 5, 2018; effective February 19, Supp. 3/31/18 A-7

9 Medical Licensure Commission Appendices Appendix C/Chapter 2 APPLICATION FOR REINSTATEMENT LICENSE NUMBER: DATE ISSUED: NAME IN FULL: (Last Name) (First Name) (Middle Name) HOME ADDRESS: CITY: STATE: ZIP CODE: COUNTY: TELEPHONE: ( ) TYPE OF PRACTICE: ALABAMA PRACTICE ADDRESS: CITY: STATE: ZIP CODE: ADDRESS DATE: SIGNATURE: Please specify the following: Public Address: Home Address Practice Address Mailing Address: Home Address Practice Address PLEASE ATTACH REINSTATEMENT FEE OF $ PLEASE ATTACH CRIMINAL BACKGROUND CHECK FEE OF $ MAKE SEPARATE CHECKS PAYABLE TO: MEDICAL LICENSURE COMMISSION OF ALABAMA ** YOU MUST SUBMIT PROOF (COPIES) OF HAVING OBTAINED TWENTY-FIVE (25) HOURS OF CONTINUING MEDICAL EDUCATION WITHIN THE PRECEDING (12) TWELVE MONTH PERIOD Supp. 3/31/18 A-8

10 Appendices Medical Licensure Commission ** ALL ACTIVE LICENSES EXPIRE DECEMBER 31 OF EACH YEAR** APPLICATION FOR REINSTATEMENT OF LICENSE To The Medical Licensure Commission of the State of Alabama I hereby make application for reinstatement of my license to practice medicine/osteopathy in the State of Alabama, Certificate Number, which automatically became inactive on the 1 st day of February 20,, for nonpayment of the annual registration fee as provided in , Code of Alabama The following information is submitted in connection with this application for reinstatement. Date: DEA #: License #: Name: Date of Birth: Social Security Number: Professional Address: Telephone: ( ) Other States or Jurisdictions in which you are currently licensed: CURRENT PRACTICE Specialty: Board Certified: Yes No Name of Board (if yes above): Date of Certification and/or Re-certification (if yes above): Practice Pattern: Percentage of Professional Time/Office: Percentage of Professional Time/Clinic: Percentage of Professional Time/Hospital: Percentage of Professional Time/Other: CURRENT PROFESSIONAL CONNECTIONS Specialty Society Member: Yes No Name of Specialty Society (if yes above): Name/Location of Hospital(s): Hospital Staff Status (active, etc.): Hospital Privileges (specify): Supp. 3/31/18 A-9

11 Medical Licensure Commission Appendices CERTIFICATION OF CME COMPLIANCE I hereby certify that I have met the annual minimum continuing medical education requirement of twenty-five 25 hours of AMA PRA Category 1 Credits or equivalent continuing medical education within the preceding twelve (12) months. Names/Results of Practice Related Examinations taken in the past year: Other (specify for the past year): 1. Have you been charged with any offense (felony or misdemeanor)? Yes No 2. Have you ever been convicted of a crime or offense (felony or misdemeanor) in the practice of medicine? Yes No 3. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? Yes No 4. Have you ever been denied a state or federal controlled substances certificate? Yes No 5. Has your certificate of qualification or license to practice medicine in any state been suspended, revoked, restricted, curtailed or voluntarily surrendered under threat of suspension or revocation? Yes No 6. Have your staff privileges at any hospital or health care facility been revoked, suspended, curtailed, limited or placed under conditions restricting your practice? Yes No 7. Have you been denied a certificate of qualification or a license to practice medicine in any state or has your application for a certificate of qualification or license to practice medicine been withdrawn under threat of denial? Yes No 8. Have you ever had a judgment rendered against you, or actions settled relating to the performance of your professional service? Yes No 9. To your knowledge, are you the subject of an investigation, or has a formal complaint against your license been filed by a licensing Board/Agency as of the date of this application since you were last licensed in this state? Yes No 10. Within the past two years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? Yes No 11. Do you currently have any mental or physical condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or mental, emotional, or nervous disorder or condition) which in any way currently affects, or if untreated could affect, your ability to practice Supp. 3/31/18 A-10

12 Appendices Medical Licensure Commission in a competent and professional manner, or within the past two (2) years have you applied for and/or have you received any payment or other compensation for any mental or physical condition? Yes No 12. Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceeding or investigation; any inquiry or other proceeding; or any proposed termination by an educational institution, employer, government agency, professional organization or licensing authority? Yes No 13. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism? Yes No 14. Are you currently engaged in the illegal use of controlled dangerous substances? Yes No 15. If your answer to the preceding question is yes, are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances? Yes No 16. Have you been, within the past five (5) years, convicted of driving under the influence (DUI) or have you been charged with DUI and been convicted of a lesser offense such as reckless driving? Yes No 17. Has your medical training or medical practice been interrupted or suspended for a period longer than 60 days for any reason other than a vacation or maternity leave? Yes No The term "currently" does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it means recently enough so that the condition referred to may have an ongoing impact on one's functioning as a physician, or within the past two years. If you have answered yes to any of the foregoing questions, please provide complete information. Supp. 3/31/18 A-11

13 Medical Licensure Commission Appendices RELEASE/CERTIFICATION I certify that the above information is currently accurate and truly reflects my professional activities. I hereby release this information for internal use to those state authorities responsible for medical licensure and/or discipline. Signature SWORN to and subscribed before me this day of, 20. Notary Public My Commission Expires: Author: Alabama Medical Licensure Commission Statutory Authority: Code of Ala. 1975, History: New Forms: Filed November 25, 2003; effective December 30, Amended: Filed April 23, 2004; effective May 28, Amended: Filed February 27, 2006; effective April 3, Amended: Filed November 30, 2007; effective January 4, Amended: Filed October 29, 2008; effective December 3, Amended: Filed April 5, 2011; effective May 10, Supp. 3/31/18 A-12

14 Appendices Medical Licensure Commission Appendix D/Chapter 2 Retired Senior Volunteer Program: Application For Restricted License To Practice Medicine Or Osteopathy Supp. 3/31/18 A-13

15 Medical Licensure Commission Appendices Author: Alabama Medical Licensure Commission Statutory Authority: Code of Ala. 1975, History: New Form: Filed September 27, 2004; effective November 1, Supp. 3/31/18 A-14

16 Appendices Medical Licensure Commission Appendix E/Chapter 2 Supp. 3/31/18 A-15

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19 Medical Licensure Commission Appendices Author: Alabama Medical Licensure Commission Statutory Authority: Code of Ala. 1975, History: New Form: Filed September 27, 2004; effective November 1, Repealed and New Rule: Filed February 27, 2006; effective April 3, Amended: Filed May 5, 2010; effective June 9, Amended: Filed January 15, 2013; effective February 19, Amended: Filed November 26, 2014; effective December 31, Amended: Filed December 1, 2015; effective January 5, Repealed and New Rule: Filed January 5, 2018; effective February 19, Supp. 3/31/18 A-18

20 Appendices Medical Licensure Commission Appendix A/Chapter 4 Application For Reinstatement Of License (Repealed 12/30/03) Author: Alabama Medical Licensure Commission Statutory Authority: Code of Ala. 1975, History: Repealed: Filed November 25, 2003; effective December 30, Supp. 3/31/18 A-19

21 Medical Licensure Commission Appendices Appendix A/Chapter 6 Application For A Special Purpose Licensed To Practice Medicine/Osteopathy Supp. 3/31/18 A-20

22 Appendices Medical Licensure Commission Appendix B/Chapter 6 Supp. 3/31/18 A-21

23 Medical Licensure Commission Appendices Author: Alabama Medical Licensure Commission Statutory Authority: Code of Ala. 1975, History: New Form (App. A & B): Filed February 25, 2005; effective April 1, Amended: Filed July 26, 2007; effective August 30, Amended: Filed January 15, 2013; effective February 19, Amended: Filed December 1, 2015; effective January 5, Repealed and New Rule: Filed January 5, 2018; effective February 19, Supp. 3/31/18 A-22

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