State Medical Board Initial Applications Application for Physician Licensure in Alaska #08-4105, Revised 02/01/16 For Medical and Osteopathic Physicians This application form has been updated. Applicants must use the new form; old versions will not be accepted. NEW: The Alaska State Medical Board is pleased to offer a new online application process for physicians called the Uniform Application for Physician State Licensure. The UA will benefit physicians by reducing redundancy in filling out multiple applications when applying for licensure in multiple states. Click Here for the Uniform Application If you experience difficulty with the uniform application, please contact customer service at: Phone: (800) 793-7939 E-mail: ua@fsmb.org Application for Resident Permit #08-4022, Revised 10/15/14 For resident physicians who wish to serve all or a portion of their residency training in Alaska Podiatry Application #08-4109, Revised 10/15/14 Includes application for temporary permit Physician Assistant Application #08-4226, Revised 10/15/14 For Certified or Graduate physician assistant Application for Locum Tenens Permit #08-4021, Revised 07/2012 For medical and osteopathic physicians Application for Physician Courtesy License 08-4288, Revised 01/31/14 Physician license for specific, limited purposes Application for Paramedic License #08-4004, Revised 10/15/14 Renewal Applications Medical License (MD/DO/DPM) Biennial License Renewal Application #08-0077, Revised 11/1/16 Mobile Intensive Care Paramedic Biennial License Renewal Application #08-0078, Revised 11/1/16 Physician Assistant Biennial License Renewal Application #08-0079, Revised 11/1/16 Supervising physician signature forms required for renewals: Mobile Intensive Care Paramedic Sponsor Physician Recommendation #08-0078a, Revised 11/1/16 Physician Assistant collaborating physician signature form Active Collaborative Plan Renewal #08-0079a, Revised 11/1/16 Miscellaneous Forms Credit Card Payment Form How to Request a License Verification Name Change, Address Change, and/or Duplicate Professional License Work History Form #08-4575, New 03/21/11 Request for Expedited Review #08-4664, New 08/10/2015 Mobile Intensive Care Paramedic Verification of Continuing Medical Education #08-4424, Revised 12/01 Periodic Record of Assessment/Physician Assistant - Certified #08-4348, Revised 05/2012 For collaborating physicians Report of Malpractice Claim Settlement #08-4285, Revised 08/2011 Request for Examination and Board Action History Report Revised 10/2010 Medical Board Change of Address #08-4011, Revised 02/09/12 Addition or Change of Mobile Intensive Care Paramedic Sponsor #08-4004(g), Revised 10/15/14 Physician Assistant Collaborative Plan form #08-4226(d) and (e), Revised 10/15/14 Addendum to Collaborative Plan Form #08-4226(e), Revised 10/15/14 Physician/Pharmacist Cooperative Practice Agreement 08-4354. Revised 09/2006 Authorization for Prescriptive Authority/Physician Assistant - Certified #08-0017, Revised 09/15/07 Verification of Status of DEA Registration #08-4105(e), Revised 10/15/14 Board Action Bank Inquiry #08-4105(f), Revised 10/15/14 Licensing Staff Contact Information Physicians (MD, DO, DPM, and Paramedics (MICP)): If your last name begins with the letters A through I, you may contact: Licensing Examiner: Deb Tempel Phone: (907) 465-2756 Email: deb.tempel@alaska.gov If your last name begins with the letters J through Q, you may contact: Licensing Examiner: Tracy Wiard Phone: (907) 465-2541 Email: tracy.wiard@alaska.gov If your last name begins with the letters R through Z, you may contact: Licensing Examiner: Olena Ziuba Phone: (907) 465-2566 Email: olena.ziuba@alaska.gov Physician Assistants: You may contact: Licensing Examiner: Dawn Hannasch Phone: (907) 465-3811 Email: dawn.hannasch@alaska.gov