INSTRUCTIONS: ALABAMA OFFICE-BASED SURGERY / PROCEDURES PHYSICIAN REGISTRATION FORM

The form discussed in this article is used by Alabama physicians to document their office-based surgery procedures. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 1: Enter your name on the first blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 2: Enter your Alabama license number on the second blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 3: Enter your street address, city, state and zip code on the third blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 4: Indicate with a check mark whether your office performs procedures using moderate sedation analgesia, in which patients are placed into a drug-induced depression of consciousness during which they respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 5: Indicate with a check mark whether your office performs procedures using deep sedation analgesia, in which patients are placed into a drug-induced depression of consciousness during which they cannot be easily aroused but can respond purposefully following repeated or painful stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 6: Indicate with a check mark whether your office performs procedures using general anesthesia, in which patients are placed into a drug-induced loss of consciousness during which they are not arousable, even by painful stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 7: Indicate with a check mark whether you as a physician meet the training requirements set forth in the Alabama Board of Medical Examiners' Office-Based Surgery Rules for moderate sedation, deep sedation and general anesthesia.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 8: Indicate with a check mark whether your office is currently accredited by the Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities, or the Joint Commission on Accreditation of Healthcare Organizations. Indicate which organization, if applicable, with a check mark.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 9: If not currently accredited, indicate with a check mark whether you plan on obtaining accreditation in the next two years.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 10: Sign and date the bottom of the form, as well as entering your Alabama medical license number.