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Applications/Forms
Please click on category below for available licensing forms. All forms may be viewed and printed with the free Adobe Acrobat Reader 6.0 or higher.
Initial Applications
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Application
for Physician Licensure in Alaska,
#08-4105,
Revised 01/2010. Application for Medical and Osteopathic
Physicians. |
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Request for Examination and Board Action History Report, Revised 02/2009. |
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Application
for Resident Permit, #08-4022, Revised 01/06/09.
Application for resident physicians who wish
to serve all or a portion of their residency
training in the state of Alaska. |
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Podiatry
Application, #08-4109, Revised 12/07. Includes
application for temporary permit. |
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Physician
Assistant Application, #08-4226, Revised 10/08.
Application for Certified or Graduate physician.
Includes locum tenens application for certified
physicians assistants. |
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Application
for Locum Tenens Permit,
#08-4021, Revised 08/27/07. For medical and osteopathic
physicians. |
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Application
for Physician Courtesy License, 08-4288,
Revised 1/03. Physician license for specific,
limited purposes. |
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Application
for Paramedic License, #08-4004, Revised 02/2009. |
For late renewals for the 2009-2010 licensing period, please contact the board office for the renewal forms.
Renewal forms for the January 1, 2011 – December 31, 2012 licensing period will be available online October 1, 2010. |
Miscellaneous Forms
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Credit Card Payment Form |
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How to Request a License Verification |
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Mobile Intensive Care Paramedic Verification of Continuing Medical Education,
#08-4424, Revised 12/01. |
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Periodic Record of Assessment/Physician Assistant - Certified, #08-4348, Revised 04/28/06. For collaborating physicians. |
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Report of Malpractice Claim Settlement, #08-4285, Revised 11/04. |
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Medical Board Change of Address, #08-4011,
Revised 07/11/07. |
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Addition or Change of Mobile Intensive Care Paramedic Sponsor, #08-4004, Revised 12/01/07. |
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Physician Assistant Collaborative Plan form, #08-4226(d) and (e), Revised 10/08. |
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Addendum to Collaborative Plan Form |
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Physician/Pharmacist Cooperative Practice Agreement, 08-4354. Revised 09/2006. |
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Authorization for Prescriptive Authority/Physician Assistant - Certified, #08-0017, Revised 09/15/07. |
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Verification of Status of DEA Registration, #08-4105e, Revised 12/2008. |
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Board Action Bank Inquiry, #08-4105f, Revised 12/2008. |
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Applications
may be viewed and
printed with Adobe
Acrobat Reader
6.0 or higher.
If you do not have
Adobe Acrobat Reader
6.0 or higher,
please click on
the Adobe logo
and download the
free software now.
If you are unable
to view or download
an application,
please contact
us by telephone
or e-mail. Providing
your complete mailing
address will enable
us to mail you
the application.
Other
application forms
may be mailed to
you or picked up
at a division office.
Completed applications
must be signed
and submitted to
the division with
the appropriate
fees.
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