Alabama Administrative Code › Title 540 - ALABAMA BOARD OF MEDICAL EXAMINERS › Chapter 540-X-7 - ASSISTANTS TO PHYSICIANS › Appendix A - APPLICATION FOR REGISTRATION OF PHYSICIAN ASSISTANT

Current through Register Vol. 42, No. 9, June 28, 2024
PHYSICIAN:
Supervising Physician Name in Full
AL Medical License Number
Medical Specialty
Board Certified
Residency Completion Date
If applicable, name of program and completion date of any
				fellowship, or other supervised training program.
Practice Address
County
Street
Apt/Suite State
Zip
Telephone Number
1. Is the physician assistant for whom registration is sought
				employed by you or by your group, partnership or professional
				corporation?
You answered No, a Supplemental Certificate must be
				submitted.
PHYSICIAN ASSISTANT
Physician Assistant Name in Full AL P. A. License Number
2. Covering Physicians
If you would like to add covering physicians to this
				registration agreement, please submit covering physician agreements.
3.
Limited Protocols
If the P.A. intends to practice under a limited protocol,
				please submit the applicable limited protocol form.
4. Core Duties and Scope Of Practice
Please submit the core duties and scope of practice
				form.
5. List each practice site where the core duties and scope of
				practice will be utilized and the number of hours this P.A. will be working
				weekly in each site. Must include name, address, and phone number of each
				site:
Remote site: Yes* No
Practice Name
Address
Phone
Hours Per Week
*If yes, provide a plan describing the practice location,
				facilities, and arrangements for appropriate communication, consultation, and
				review.
6. Specify a plan for quarterly quality assurance management
				with defined quality outcome measures for evaluation of the clinical practice
				of the physician assistant and include review of a meaningful sample of medical
				records plus all adverse outcomes. The term "medical records" includes, but is
				not limited to, electronic medical records.
Documentation of quality assurance review shall be readily
				retrievable, identify records that were selected for review, include a summary
				of findings conclusions, and, if indicated, recommendations for change.
Supervising Physician Initials
Physician Assistant Initials
7. Will this P. A. be authorized to have prescriptive
				privileges?
You answered Yes, comlete the Formulary which is a list of the
				legend drugs which are authorized by the Physician to be prescribed by the P.
				A. The formulary approved under the rules of the Board of Medical Examiners
				should be utilized and attached as the authorized legend drugs to be
				prescribed. The medication categories chosen should reflect the needs of the
				supervising physician's medical practice.
8. Will this P. A. be authorized to have prescriptive
				privileges to prescribe controlled substances as allowed under Alabama Code
				Section 20-2-60, et. seq.? (Prerequisites
				for controlled substances prescribing by P.A.s are stated in Board Rules,
				Chapter 540-X-12)
If yes, the application for a Qualified Alabama Control
				Substance Certificate can be found at our web site,
www.albme.gov
.
We hereby certify under penalty of law of the State of Alabama
				that the foregoing information in this Physician Assistant Job Description is
				correct to the best of our knowledge and belief. We certify that we have
				reviewed the current rules of the Alabama Board of Medical Examiners pertaining
				to assistants to physicians and understand our responsibilities. We understand
				that we are equally responsible for the actions of the Assistant to the
				Physician.
Under Alabama law, this document is a public record and will be
				provided upon request
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.
Knowingly providing false information to the Alabama Board of
				Medical Examiners or Medical Licensure Commission of Alabama could result in
				disciplinary action.
SUPPLEMENTAL CERTIFICATE TO APPLICATION FOR REGISTRATION
				AS A PHYSICIAN ASSISTANT
To:
				____________________________________________________________
(Name and Address of Hospital or Corporate Employer)
The State Board of Medical Examiners has been presented with an
				application from _______________________________________, P. A., for
				certification as a physician assistant to _____________________________, M.D.
				Information available to the Board indicates that
				________________________________, M.D., is an employee of
				___________________________________________________________(legal entity), and
				that_________________________, Physician Assistant, is an employee of
				_______________________________________________ (legal entity).
To assist the Board in evaluating this application, it is
				requested that this questionnaire be filled out and executed by the President,
				Chairman, Chief Executive Officer or Chief Administrative Officer of the
				corporation or other legal entity that employs the physician and/or the
				physician assistant. These questions relate directly to the supervisory
				relationship contemplated by Board Rules, Chapter 540-X-7. When an additional
				explanation is to be provided, please attach additional information on separate
				pages.
1. Is the physician whose name appears above, employed by you
				to engage in the full-time practice of medicine? If the answer to this question
				is no, please provide the Board with details of the employment agreement
				between your corporation and the physician.
2. Does the physician whose name is stated above have the
				unqualified authority to terminate the employment of the physician assistant
				registered to him/her? If the answer to this question is no, please set out in
				detail the steps required to terminate the employment of the physician
				assistant and identify the officer or officers of the corporation authorized to
				make that decision.
3. Does the physician whose name is stated above, have the
				unqualified authority to determine the levels of compensation to be paid to the
				physician assistant registered to him/her? If the answer to this question is
				no, please set forth in detail the manner in which the compensation of the
				physician assistant is established and the identification of the officer or
				officers of the corporation who are authorized to establish, increase or reduce
				the compensation of the physician assistant.
4. Does the physician whose name appears above have the
				unqualified authority in matters relating to patient care to enforce compliance
				with orders and directives issued to the physician assistant? Please describe
				in detail the manner in which such orders and directives may be
				enforced.
5. Is the physician assistant whose name appears above subject
				to the supervision, direction or control of any officer, director, supervisor
				or employee of the corporation other than the physician to whom he/she is
				registered? If the answer to this question is yes, please explain in detail,
				identifying the individual exercising the supervision, direction or control and
				the circumstances in which such supervision, direction and control would be
				exercised.
6. In matters relating to patient care, is the physician
				assistant whose name appears above subject to the immediate supervision,
				direction or control of any non-physician?
If yes, explain the relationship.
7. Will the physician assistant whose name appears above be
				expected or required to perform any part of his/her duties at any time when the
				physician to whom he/she is registered is not on duty and physically present on
				the premises of the hospital, clinic, or facility where the physician's
				assistant services will be rendered? If the answer to this question is yes,
				please explain in detail all such circumstances.
I understand that the information submitted herein is to be
				used by the Board of Medical Examiners as the basis for registration of a
				physician assistant and that the furnishing of false or misleading information
				or the future occurrence of substantial departures from or violations of the
				standards and procedures outlined in this response may be considered by the
				Board as grounds for termination of the registration of the physician
				assistant.
The undersigned hereby certifies that the foregoing information
				is true and correct to the best of my knowledge, information and belief
________________________________________________________________
Name of the Corporation Title of Officer Signing
				Certificate
________________________________________________________________
Printed Name of the Officer Signing Certificate
				Signature
This form may be sent to the Board via facsimile or email (see
				instructions)
Author:
Alabama Board of Medical
				  Examiners
Statutory Authority:
Code of Ala. 1975, §
										34-24-290, et.
				  seq.