Ala. Admin. Code 540, ch. 540-X-7, app A
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)
Ala. Admin. Code 540, ch. 540-X-7, app A
Author: Alabama Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, § 34-24-290, et. seq.