State Medical Board Applications & Forms Emergency Medical Courtesy License Due to the COVID-19 emergency and in line with SB 241, the State Medical Board has developed a process for Emergency Courtesy Licenses. This process is NOT intended to be a method to expedite the initial licensure process. To expedite review of an initial application, please complete the Request for Expedited Review Form. Medical Emergency Courtesy License, Online Application Filed through MyAlaska account. Online Application Instructions Medical Emergency Courtesy License, Paper Application #08-4735, Revised 5/07/2020 Physician Assistant Emergency Courtesy License, Online Application Filed through MyAlaska account. Online Application Instructions Physician Assistant Emergency Courtesy License, Paper Application #08-4736, Revised 5/07/2020 Physician Assistances licensed under 12 AAC 40.045 Courtesy License are not required to have a collaborative plan. Mobile Intensive Care Paramedic Emergency Courtesy License, Online Application Filed through MyAlaska account. Online Application Instructions Mobile Intensive Care Paramedic Emergency Courtesy License, Paper Application #08-4737, Revised 5/07/2020 Initial Applications Review the FAQs page for important information about applying for licensure and practicing in the State of Alaska. Physician (MD, DO, DPM) MD/DO Online application for licensure Filed through your MyAlaska account. Also allows for email notifications about your application status. Uniform Application (UA) for initial licensure Offered through the Federation of State Medical Boards (FSMB) to benefit physicians applying for licensure in multiple states. FSMB customer service: Phone 800-793-7939. Email: ua@fsmb.org MD/DO Paper Application for Initial Licensure #08-4105, Revised 02/01/19Application for Physician Licensure in Alaska Application for Resident Permit #08-4022, Revised 2/01/19 For resident physicians who wish to serve all or a portion of their residency training in Alaska. Podiatry Application #08-4109, Revised 2/01/19 Includes application for temporary permit. Application for Locum Tenens Permit #08-4021, Revised 2/01/19 For medical and osteopathic physicians. Application for Physician Courtesy License 08-4288, Revised 12/07/18 Physician license for specific, limited purposes. Physician Assistant Online application for licensure Filed through your MyAlaska account (coming soon). Also allows for email notifications about your application status. Paper Application for Initial Licensure #08-4226, Revised 2/01/19 Application for certified or graduate physician assistants Physician Assistant Collaborative Plan #08-4226(d) and (e), Revised 2/01/19 Addendum to Collaborative Plan #08-4226(e), Revised 2/01/19 Authorization for Prescriptive Authority/Physician Assistant – Certified #08-0017, Revised 9/15/07 Periodic Record of Assessment/Physician Assistant – Certified #08-4348, Revised 05/2012 Mobile Intensive Care Paramedic (MICP) Online application for licensure Filed through your MyAlaska account (coming soon). Also allows for email notifications about your application status. Paper Application for Initial Licensure #08-4004, Revised 2/01/19 Application for paramedic license. Addition or Change of Mobile Intensive Care Paramedic Sponsor #08-4004(g), Revised 10/15/14. Board-Issued Guideline Regarding Paramedic CME Continuing medical education requirements and what is accepted by the Board. Mobile Intensive care Paramedic Verification of Continuing Medical Education #08-4424, Revised 12/01. Renewal Applications Review the FAQ page for important information about CME requirements for renewals, including the new legislative requirement for education in pain management and opiod use and addiction. The Alaska Department of Health and Social Services also published a resource page for opioid CME on their website: CME on opioids Paper application for MD, DO, DPM license renewal Medical License (MD/DO/DPM) License Renewal Application, #08-0077, Revised 11/01/18 Paper application for PA license renewal Physician Assistant License Renewal Application, #08-0079, Revised 11/01/18 Supervising physician signature form required for PA renewal Active Collaborative Plan Renewal, #08-0079a, Revised 11/01/18 Paper application for MICP license renewal Mobile Intensive Care Paramedic License Renewal Application, #08-0078, Revised 11/01/18 Sponsor physician signature form required for MICP renewal Mobile Intensive Care Paramedic Sponsor Physician Recommendation, #08-0078a, Revised 11/1/16 Board-issued Guidelines Regarding Paramedic CME Continuing medical education (CME) requirements and what is accepted by the Board Form used to explain and document "Yes" answer(s) to Professional Fitness questions Letter of Explanation, #08-4752, Revised 01/02/18 Miscellaneous Forms Online application for licensure Filed through your MyAlaska account (coming soon). Also allows for email notifications about your application status. Online License Verification Use if you need a verification of your Alaska physician license sent to another state medical board. The fee is $30. The verification will be sent via computer and so transfer of information occurs immediately. Request a License Verification Name Change, Address Change, and/or Duplicate Professional License Online Address Change Filed through your MyAlaska account. Credit Card Payment Form 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 12/07/18 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 whose last name begins with the letters A through I and Physician Assistants may contact: Licensing Examiner: Jason Kaeser Phone: (907) 465-2781 Email: jason.kaeser@alaska.gov Physicians whose last name begins with the letters J through N may contact: Licensing Examiner: Steven Alvarado Phone: (907) 465-1077 Email: steven.alvarado@alaska.gov Physicians whose last name begins with the letters O through Z and Paramedics may contact: Licensing Examiner: Olena Ziuba Phone: (907) 465-2566 Email: olena.ziuba@alaska.gov Medical licensing general contact: Phone: (907) 269-8163 Email: medicalboard@alaska.gov -->