Answer Yes or No (If any below answers are in the affirmative, please explain in detail and provide the complete name and address of any state board, hospital, psychiatrist/psychologist etc.)
Have you ever been convicted of a felony?
Have you ever been convicted of a crime or offense (felony or misdemeanor) related to the practice of medicine?
Have you ever been convicted of any violation of a state or federal law relating to controlled substances?
Has your DEA registration or any state controlled substance certificate been denied or subject to any discipline, including but not limited to the following: revocation; suspension; probation; restriction(s); condition(s); reprimand or fine; or has your DEA registration or any state controlled substance certificate been voluntarily surrendered while under investigation?
Has your certificate of qualification or license to practice medicine in any state been denied or subject to any discipline, including but not limited to the following: revocation; suspension; probation; restriction(s); condition(s); reprimand or fine; or has your certificate of qualification or license to practice medicine in any state been voluntarily surrendered while under investigation or under threat of discipline?
Have your staff privileges at any hospital or health care facility been revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?
Have you ever 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medicine in any state or has your application for a certificate of qualification or license to practice medicine been withdrawn under threat of denial?
Have you ever had a judgment rendered against you, or action settled relating to performance of your professional service?
To your knowledge, are you the subject of an investigation or proposed action by any licensing board/agency as of the date of this application?
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?
Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?
Are you currently* engaged in the excessive use of alcohol, controlled substances, or the use of illegal drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues or mental health issues? (If 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 answer for this purpose will not be deemed upon certification as providing false information to the Alabama Board of Medical Examiners or the Medical Licensure Commission of Alabama).
*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 within the past two years.
Within the past five years, have you been 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?
Has your medical education, training or 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?
Declaration of Citizenship
Review Page – If everything is correct, press “Next”
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116