List all states where you are licensed to practice medicine or osteopathy.
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 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any state or has your application for a certificate of qualification or license to practice medicine or osteopathy been withdrawn under threat of denial?
Has a disciplinary action or investigation been initiated in any state in which you currently hold a license to practice medicine or osteopathy?
Declaration for Certificate of Qualification for Special Purpose License
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.
Declaration of Citizenship
Review Page – If everything is correct, press “Next”
Board of Medical Examiners charge will appear on your statement with a description including IGOVSOL*
P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116