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Instructions

Application for Certificate of Qualification For a Special Purpose License to Practice Medicine or Osteopathy

The following item(s) will need to be uploaded during the online application process:

Declaration of Citizenship (completed form with supporting documents)

Color photograph (taken within 60 days prior to the date of this application)

Under Alabama law, this document is a public record and will be provided upon request.

Please review Board Rules, Chapter 540-X-16, the Practice of Medicine Across State Lines.

Special Purpose licensees are limited solely to the practice of medicine or osteopathy across state lines (may not come into Alabama and practice).

Qualifications for a Special Purpose Certificate of Qualification:

Applicant's principal practice location and license is in a state/territory whose laws permit or allow issuance of a license to practice medicine across state lines or a similar license.

Applicant holds a full and unrestricted license in any and all states in which the applicant is licensed

Applicant has not had any previous disciplinary action or other action taken by any state or licensing jurisdiction (the Board may waive this requirement if it finds the disciplinary action does not indicate that the physician is a potential threat to the public)

Initial license fee is $175.00

To the Alabama Board of Medical Examiners:

I hereby make application for a certificate of qualification to practice medicine or osteopathy across state lines in the State of Alabama, and submit the following statement concerning my qualifications for a special purpose license.

Demographics

First Name

Middle Name

Last Name

Alternate Name(s)

Suffix

MD or DO

Contact Information

The address and contact methods provided should be how the Board or Commission can contact the license applicant directly. Please DO NOT provide contact information for office managers, assistants, or license credentialing agencies.

Principal Practice Address

Country

Street

Apt/Suite

City

State

Zip

Contact Methods

Email Address

Home Telephone Number

Work Telephone Number

Place of Birth

Country of Birth

State/Providence of Birth

City of Birth

Date of Birth

Social Security Number

Gender/Sex

*(Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued).

Upload a color photograph taken within 60 days prior to the date of this application.

Regulatory Questions

Answer Yes or No (If any below answers are in the affirmative, please explain in detail)

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?

Yes

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 or osteopathy been withdrawn under threat of denial?

Yes

Has a disciplinary action or investigation been initiated in any state in which you currently hold a license to practice medicine or osteopathy?

Yes

Declaration for Certificate of Qualification for Special Purpose License

In connection with my application for a certificate of qualification for a special purpose license to practice medicine or osteopathy across state lines, I understand and acknowledge that:

A. A special purpose license only permits the holder to engage in the practice of medicine across state lines on patients located in the State of Alabama but does not authorize the holder to be physically present and engage in the general practice of medicine within the State of Alabama.

B. It is the affirmative duty of the holder of a special purpose license to report to the Alabama Board of Medical Examiners in writing within fifteen days of the initiation of any disciplinary action against the license to practice medicine or osteopathy of the licensee by any state or territory in which the license is licensed.

C. By accepting a special purpose license, the licensee agrees to produce patient records or materials as requested by the Board of Medical Examiners or the Medical Licensure Commission and to appear before the Board or the Commission or any of its committees following the receipt of a written notice by the Board or Commission.

D. The issuance of a special purpose license subjects the licensee to the jurisdiction of the Alabama Board of Medical Examiners and the Medical Licensure Commission of Alabama and the respective statutes and regulations under which they operate, including all matters related to discipline.

E. Failure to renew a special purpose license according to the renewal schedule shall result in the automatic revocation of the special purpose license. In the event of the automatic revocation of a special purpose license for failure to renew, the licensee must reapply for a new special purpose license.

Release

certify that all of the information supplied in the foregoing application is true and correct to the best of my knowledge, that the photograph submitted is a true likeness of myself and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this application may result in the revocation of my license to practice medicine and criminal prosecution to the fullest extent of the law.

I further consent to and authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information, and I release the Alabama Board of Medical Examiners from all liability for the release of this information. I further consent to and authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners, and I release this individual or organization from any liability for the release of information.

I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief.

Date

Applicant’s typed name

Declaration of Citizenship

DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt “qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive covered state or local public benefits.

With certain exceptions, Ala. Code § 31-13-1, et. seq. prohibits aliens unlawfully present in the U.S. from receiving state or local benefits. Every U.S. Citizen applying for a state or local public benefit must sign a Declaration of Citizenship, and the lawful presence of an alien in the U.S. must be verified by the Federal Government.

Ala. Code § 31-13-1, et. seq. also requires every individual applying for a permit or license to demonstrate his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate his/her lawful presence in the United States.

Upload Declaration of Citizenship (completed form and supporting documentation)

Review Page – If everything is correct, press “Next”

Payment

Payment Deferral

E-Signature

Date

Total Amount

Payment Type

Person’s Name on Card

Card Type

Person's Name on Account

Card Number

Expiration Date (MM/YY)

Security Code

Routing Number

Account Number

Account Type

Billing Zip Code

Board of Medical Examiners charge will appear on your statement with a description including IGOVSOL*

Alabama	Alaska	Alberta	American Samoa	Arizona
Arkansas	Armed Forces Americas	Armed Forces Canada	Armed Forces Europe (FPO)	Armed Forces Pacific (APO)
British Columbia	California	Canada	Colorado	Connecticut
Delaware	District of Columbia	Fed St Micronesia	Florida	Georgia
Guam	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Louisiana	Maine
Manitoba	Marshall Islands	Maryland	Massachusetts	Michigan
Minnesota	Mississippi	Missouri	Montana	Nebraska
Nevada	New Brunswick	New Hampshire	New Jersey	New Mexico
New York	Newfoundland	North Carolina	North Dakota	Northern Mariana Island
Northwest Territories	Not Known	Nova Scotia	Nunavut	Ohio
Oklahoma	Ontario	Oregon	Other Country	Palau
Pennsylvania	Prince Edward Island	Puerto Rico	Quebec	Rhode Island
Saskatchewan	South Carolina	South Dakota	Tennessee	Texas
Unknown	Utah	Vermont	Virgin Islands	Virginia
Washington	West Virginia	Wisconsin	Wyoming	Yukon