Physician assistant registration termination request form

* indicates a required field

Physician's information

Physician's practice address

PA information

PA's practice address


PA ceased providing services under the registration agreement on



By entering your name and clicking the submit button I certify that the physician has read and understands the Alabama Board of Medical Examiners Rule 540-X-7-.20 regarding termination. I also understand that failure to adhere to the rules may result in an action against my license.


 

This form uses Huggins' Email Form Script

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