Replacement annual renewal certificate request form

* indicates a required field


If you don't need a duplicate certificate for your primary license, please leave "none" selected and choose a secondary certificate from the secondary list below.


None
MD - Medical Doctor
DO - Doctor of Osteopathy
L - Limited MD and Limited DO
PA - Physician Assistant
AA - Anesthesiologist Assistant
RSV - Retired Senior Volunteer Program
SP - Special Purpose


If you don't need a duplicate certificate for your secondary license, please leave "none" selected and choose a primary certificate from the secondary list above.

If you need a duplicate CP certificate, please provide the CRNP/CNM's name in the adjacent box. If you need more than one CP, list the additional names in the additional information box below.


None
ACSC - Alabama Controlled Substances Certificate (MD, DO, L ONLY)
QACSC - Qualified Alabama Controlled Substances Certificate (PA ONLY)
CP - Collaborative Practice



 

 

This form uses Huggins' Email Form Script

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