Collaborative practice termination notice

* indicates a required field

Physician's information

CRNP/CNM information

CRNP/CNM ceased providing services under the collaborative practice agreement on

By entering your name and clicking the submit button, you certify that the physician has read and understands the Alabama Board of Medical Examiners Rule 540-X-8-.04 (4) (b) regarding termination and, if you are not the physician, you certify that the physician has authorized you to terminate the collaborative practice on the physician's behalf. Failure to adhere to the Board rules could result in action against the physician's license.


 

This form uses Huggins' Email Form Script

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