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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 11/2012. Application for Medical and
Osteopathic Physicians. |
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Request
for Examination and Board Action History Report, Revised
10/2010. |
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Application for
Resident Permit, #08-4022, Revised 09/2012. 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 11/2012. Includes application for temporary
permit. |
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Physician Assistant
Application, #08-4226,
Revised 11/2012. Application for Certified or Graduate physician assistant. |
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Application for Locum
Tenens Permit, #08-4021, Revised 07/2012. For medical and
osteopathic physicians. |
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Application for
Physician Courtesy License, 08-4288, Revised 11/2012. Physician
license for specific, limited purposes. |
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Application for
Paramedic License, #08-4004, Revised 09/2012. |
Online Renewal of Medical Licenses is no longer available.
You may download one of the following renewal applications:
Medical License (MD/DO/DPM) Renewal Application, #08-0077, Revised 09/18/12. For license numbers 1 through 7326
Prorated Medical License (MD/DO/DPM) Renewal Application, #08-0076, Revised 09/18/12. For license numbers 7327 and above.
Mobile Intensive Care Paramedic License Renewal Application, #08-0078, Revised 09/18/12.
Physician Assistant License Renewal Application, #08-0079, Revised 09/18/12.
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
05/2012. 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 02/09/12. |
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Addition or Change of
Mobile Intensive Care Paramedic Sponsor, #08-4004(g), Revised
09/2012. |
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Physician Assistant
Collaborative Plan form, #08-4226(d) and (e), Revised 11/2012. |
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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, #08-4105(e), Revised 11/2012. |
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Board Action Bank
Inquiry, #08-4105(f), Revised 11/2012. |
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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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