Instructions
It is the responsibility of the A.A. to submit an application in a timely manner to ensure it is received and reviewed by the Board within the intended month. Click here to access the Board’s agenda deadline schedule. Before you begin, you should thoroughly read Board Rules, Chapter 540-X-7, Assistants to Physicians. Click here to read the rules. Both a state license and a registration agreement to a supervising physician are required to practice as an anesthesiologist assistant in Alabama. Presently, an initial license and registration agreement may be obtained at the same time. Although licensing is a one-time process, a registration agreement is required for each new professional relationship. Before you begin this application, review the list below and ensure you have each of the required documents and available funds. Once you begin the application process, you will not have the opportunity to save and complete the application at a later time. Please ensure you have what is required before you begin. The following items are required to complete the online application: 1) Diploma reflecting graduation from an approved A. A. training program (Transcripts are not acceptable) 2) NCCAA certificate/certification of successful completion of the examination 3) Funds of $265.00 for the payment of the license fee and the criminal history background check 4) Supporting documentation for Declaration of Citizenship; click here to view a list of valid documents 5) Color photograph taken within sixty days prior to the date of this application Fingerprint Card Request You must request fingerprint cards for your criminal background check. Send an email to [email protected]. Please be sure to include your mailing address in your email request. You must also submit the Application To Review Alabama Criminal History Record Information to conduct your criminal background check. This form should be mailed to the Board along with your two completed fingerprint cards. Click here to obtain the required form. Note: Waiting to receive information from another entity can cause delays in a licensure application being placed on the Board's agenda (i.e., license verification from other states, copy of a diploma, and criminal background results).
Screen Guide
Demographics
Background Information
Have you ever been arrested for, cited for, charged with, or convicted of any crime, offense, or violation of any law, felony, or misdemeanor, including, but not limited to, offenses related to the practice of medicine or state or federal controlled substances laws? *This question excludes minor traffic violations such as speeding and parking tickets but includes felony and misdemeanor criminal matters that have been dismissed, expunged, sealed, subject to a diversion or deferred prosecution program, or otherwise set aside.
Have you ever been arrested for, cited for, charged with, or convicted of any sex offender laws or required to register as a sex offender for any reason?
Have you ever had a judgment rendered against you or action settled relating to an action for injury, damages, or wrongful death for breach of the standard of care in the performance of your professional service ("malpractice")?
To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any law enforcement agency?
Have you ever had any Drug Enforcement Administration registration and/or state controlled substances registration denied, voluntarily surrendered while under investigation, or subject to any discipline, including, but not limited to revocation, suspension, probation, restriction, conditions, reprimand, or fine?
Have you ever been denied prescription privileges for non-controlled or legend drugs by any state or federal authority?
Have you ever been denied a license to practice as an assistant to physicians in any state or jurisdiction or has your application for a license to practice as an assistant to physicians been withdrawn under threat of denial?
Has your certification or license to practice as an assistant to physicians in any state or jurisdiction ever been subject to any discipline, including but not limited to revocation, suspension, probation, restrictions, conditions, reprimand, or fine?
Have your privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?
To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any federal agency, any licensing board/agency, or any hospital or health care facility?
Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?
Within the past five years, have you 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 during 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?
Within the past five years, have you been convicted of driving under the influence (DUl), or have you been charged with DUI and been convicted of a lesser offense such as reckless driving?
Are you currently* engaged in the excessive use of alcohol or controlled substances or in the use of illegal drugs, or receiving any therapy or treatment for alcohol or drug use, sexual boundary issues, or mental health issues? *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 that the condition referred to may have an ongoing impact on one's functioning as an assistant to physicians within the past two years.
Notice: lf you are an anonymous participant in the Alabama Professionals Health Program and are in compliance with your contract, you may answer "No" to this question. Such an answer for this purpose, upon certification, will not be deemed as providing false information to the Alabama Board of Medical Examiners.
IMPORTANT: The Board recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other health care providers do. Licensees are expected to address their health concerns and ensure patient safety. Options include anonymously self-referring to the Alabama Professionals Health Program (334-954-2596), an advocacy organization dedicated to improving the health and wellness of medical professionals in a confidential manner. The failure to adequately address a health condition where the licensee is unable to practice medicine with reasonable skill and safety to patients can result in the Board taking action against the license to practice as an assistant to physicians.
Education/Training/Experience
Examination/Current Practice Information
Certification of Licensure in Other States
Select all states where you have been certified/registered/licensed as an assistant to physicians. Primary source verification is required from any state that does not report anesthesiologist assistant data to the Federation of State Medical Boards.
Click Here to print a license verification form
List A
List B
Citizenship-U.S. Citizenship or National Status
Citizenship-Declaration
I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided are true and correct to the best of my knowledge.
Certification and Release
Review Page – If everything is correct, press “Next”
Affirm And Submit
Board of Medical Examiners charge will appear on your statement with a description including IGOVSOL*
When entering attendance dates below, you may use the first date of the month instead of the exact date. (Ex: attended August 1990 – July 1994, enter 08/01/1990 – 07/01/1994)
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116