Ala. Admin. Code 540, ch. 540-X-19, app B
20XX Application for Renewal of Alabama Pain Management Registration
Deadline: December 31, 20XX
Under Alabama law, this document is a public record and if requested it will be provided in its entirety.
Licensee's Name
Primary License Number
Location Name
Location Address
1. Do you provide pain management services at a hospital? Yes No In the past year, have either you or the owner(s) of each location where you provide pain management services been convicted of or pled nolo contendere to a felony or an offense that constitutes a misdemeanor, the facts of which relate to the distribution or illegal prescribing of any controlled substance?* Yes No (If yes, please include a detailed explanation)
*Any applicant who has been convicted of a crime described in this paragraph may request an interview before the Board, after which the Board, in its discretion, may approve or deny the registration.
2. Does the location listed above at which the above licensee provides pain management services have a medical director as required by Board Rule 540-X-19-.04 ? Yes No
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 could result in disciplinary action.
Ala. Admin. Code 540, ch. 540-X-19, app B
Author: Alabama Board of Medical Examiners
Statutory Authority:Code of Ala. 1975, §§ 34-24-53.