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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 05/2011. 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 03/2011. 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 05/2011. Includes application for temporary
permit. |
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Physician Assistant
Application, #08-4226,
Revised 03/2011. 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 05/2011. For medical and
osteopathic physicians. |
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Application for
Physician Courtesy License, 08-4288, Revised 03/2011. Physician
license for specific, limited purposes. |
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Application for
Paramedic License, #08-4004, Revised 02/2011. |
Miscellaneous Forms
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Credit Card Payment Form |
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How to Request a
License Verification |
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Request Duplicate Professional License |
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Work History Form, #08-4575, New 03/21/11 |
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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 08/2011. |
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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(f ), Revised
02/2011. |
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Physician Assistant
Collaborative Plan form, #08-4226(d) and (e), Revised 03/2011. |
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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 05/2011. |
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Board Action Bank
Inquiry, #08-4105f, Revised 05/2011. |
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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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