State Medical Board Applications & Forms Attention Emergency Courtesy Licensee Applicants! Effective July 1, 2022 no new ECL applications or ECL Extension applications will be accepted. Expedited temporary licensing is available with the full application process. Please email medicalboard@alaska.gov for more information. 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 03/11/2022Application for Physician Licensure in Alaska Application for Resident Permit #08-4022, Revised 03/11/2022 For resident physicians who wish to serve all or a portion of their residency training in Alaska. Application for Podiatrist License #08-4109, Revised 03/11/2022 Includes application for temporary permit. Application for Locum Tenens Permit #08-4021, Revised 03/11/2022 For medical and osteopathic physicians. Application for Physician Courtesy License #08-4288, Revised 03/11/2022 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. Application for Physician Assistant (PA) #08-4226, Revised 03/11/2022 Application for certified or graduate physician assistants. Physician Assistant Collaborative Plan #08-4226(d), Revised 03/11/2022 Addendum to Collaborative Plan #08-4226(e), Revised 03/11/2022 Authorization for Prescriptive Authority/Physician Assistant – Certified #08-0017, Revised 09/15/2007 Periodic Record of Assessment/Physician Assistant – Certified #08-4348, Revised 05/2012 Renewal Applications Paper application for MD, DO, DPM license renewal Medical License (MD/DO/DPM) License Renewal Application, #08-0077, Revised 1/5/2021 Paper application for PA license renewal Physician Assistant License Renewal Application, #08-0079, Revised 1/5/2021 Renewal applications will be available no later than December 1, 2022, in accordance with AS 08.01.050. Please note, you must wait for an updated renewal application to renew your license. You cannot renew your license using any prior renewal forms. If you need to renew your license for the current licensing period (1/1/2021 – 12/31/2022), email medicalboard@alaska.gov to request the appropriate form. To ensure receipt of renewal notifications and other correspondence from our office, please go to MY LICENSE and confirm your current mailing address is on file. Prior to renewal, check out our License Renewal Prep guide. If you are a Primary Collaborating Physician for Physician Assistant(s) and/or Sponsor Physician of Mobile Intensive Care Paramedic(s) get a head start by completing these forms prior to renewal. For your convenience, these forms also available through your MY LICENSE account. Completed forms can be uploaded through MY LICENSE, see the instructions listed below for more details. Instructions for Active Collaborative Plan Renewal Collaborative Plan Renewal Form #08-0079a, Revised 09/16/2022 Review the FAQ Page for important information about CME requirements for renewals, including the legislative requirement for education in pain management and opioid use and addiction. Miscellaneous Forms Online License Verification via VeriDoc 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 - transfer of information occurs immediately. Periodic Record of Assessment/Physician Assistant - Certified #08-4348, Revised 05/2012 For collaborating physicians Report of Malpractice Claim Settlement #08-4833, Revised 09/10/2021 Request for Examination and Board Action History Report Physician-Pharmacist Cooperative Practice Agreement #08-4410, Revised 07/08/2022 Authorization for Prescriptive Authority/Physician Assistant - Certified #08-0017, Revised 09/15/07 IHS Provider State Licensure Exemption#08-4853, New 05/04/2022 Division forms may be found in the CBPL Quick links, located in the sidebar to the right. Licensing Staff Contact Information Physicians whose last name begins with the letters A through J, 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 K through Q may contact: Licensing Examiner: Jacob Olsen Phone: (907) 465-2566 Email: jacob.olsen@alaska.gov Physicians whose last name begins with the letters R through Z may contact: Alisa Perkins Phone: (907) 465-1077 Email: alisa.perkins@alaska.gov Medical licensing general contact: Phone: (907) 269-8163 Email: medicalboard@alaska.gov