INSTRUCTIONS: ALABAMA APPLICATION FOR REINSTATEMENT OF PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE

To apply for a reinstatement of a physician assistant or anesthesiologist assistant license in Alabama, use the form discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 1: On line 1, enter your name.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 2: On line 2, enter your address.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 3: On line 3, enter your initial license number and the date on which it was issued.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 4: On line 4, enter the date of revocation, suspension or surrender of the license.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 5: On line 5, enter your Social Security number and date of birth.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 6: On line 6, provide a detailed explanation of the reasons for the revocation, suspension or surrender of your license. If necessary, this may be continued on an additional sheet of paper.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 7: Answer questions 1 through 7 by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 8: Answer questions 2 through 4 by checking "Yes" or "No" as applicable. If you answer yes to question 4, attach a list with the name and principal practice location of each primary supervising physician to whom you are certified in another state.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 9: Answer questions 5 and 6 at the bottom of the first page by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 10: On the second page, answer questions 6 through 12 by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 11: Enter your signature where indicated.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 12: List all states in which you hold or have applied for licensure. Have the form certified by a notary public.