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 a license to practice medicine in any state or jurisdiction or has your application for a license to practice medicine been withdrawn under threat of denial?
Has your certificate of qualification or license to practice medicine 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Have your staff privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?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 a physician 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 or the Medical Licensure Commission of Alabama.
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), a physician 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 action being taken against the license to practice medicine.
Has your medical education, training, or medical practice been interrupted or suspended, or have you ceased to engage in direct patient care, for a period longer than 60 days for any reason other than a vacation or for the birth or adoption of a child?
Have you ever been placed on academic or disciplinary probation by, or been required to remediate any portion of, a medical school or postgraduate program?
Were limitations or special requirements imposed on you because of questions of academic, clinical, or disciplinary problems, or any other reason during your medical education or postgraduate training, such as repeating a class or classes or taking time off from school to study for an examination?
Have you ever been disciplined for unprofessional conduct/behavior reasons by a medical school or postgraduate program?
Declaration of Citizenship
Review Page – If everything is correct, press “Next”
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116