Collaborative Practice Helpful Information

*Alabama Board of Medical Examiners: www.albme.org

*Collaborative Practice Rules found: www.albme.org under Legal / Administrative Rules 540-X-8

*Collaborative Practice Nurse Consultants: Patricia Ward [email protected] 334-833-0186 Amy Wybenga [email protected] 334-833-0193 Collaborative Practice Administrative Assistant Linda Stripling [email protected] 334-833-0199

*Quality Assurance Samples Send an email to [email protected] or [email protected] with the subject line being Quality Assurance Samples and we will send general QA samples. If you would like samples for a specific type practice i.e. Pediatrics, Internal Medicine, OB/GYN includes a brief message telling us the type practice you have and we will try to send more specific samples.

*Commencement Form: http://www.albme.org/Documents/Forms/collpraccommform.pdf

A Commencement Form and the Fee for $100.00 per Collaborative Agreement must be submitted to the Board of Medical Examiners prior to Temporary Approval being issued by the ABN. Always use the current updated Commencement Form from the website

*Termination Notice: http://www.albme.org/terminationform.html Termination Notice must be submitted by the physician to the Board of Medical Examiners before a Collaborative Practice will be removed from his/her license. Easy submission from website!

* Change of Address (practice and/or mailing): http://www.albme.org/Documents/Forms/addchangerrequ.pdf

*Laser Registration Form: http://www.albme.org/Documents/Forms/laserregis.pdf

*QACSC Application Link: http://www.albme.org/Documents/Forms/QACSCNPapp.pdf

*LPSP Application Link: http://www.albme.org/Documents/Forms/LPSP%20application.pdf

Always check the website before submitting an LPSP application as the Formulary could change and you want to submit the most recently approved Formulary page.

*Alabama Board of Nursing: www.abn.alabama.gov (Online application for Collaborative Practice)  Initial Application – for new graduates or for those who have never had a Collaborative Agreement in the State of Alabama  Add Collaborative Practice—for those who are either changing from one collaborating physician to another or adding an additional collaboration  Modification-used to add covering physicians, change hours, add or change practice information, request additional skills or any other changes to the existing collaborative agreement.