State Medical Board Applications & Forms Emergency Courtesy License: Due to the COVID-19 emergency declared by the governor, the State Medical Board has adopted regulations to allow for an Emergency Courtesy License. Emergency Courtesy License, Online Applications Physician and Osteopath Courtesy License, Paper Application#08-4735, Revised 03/17/2021 Physician Assistant Emergency Courtesy License, Paper Application#08-4736, Revised 03/17/2021 Extensions: Emergency Courtesy Licenses are issued for six months and may be extended for one additional six-month period if the board has determined the urgent situation still exists. Use one of the following forms to request an extension of your Emergency Courtesy License. MD/DO Emergency Courtesy License Extension, Paper Application#08-4806, New 03/17/2021 Physician Assistant Emergency Courtesy License, Paper Application#08-4807, New 03/17/2021 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 04/05/2021Application for Physician Licensure in Alaska Application for Resident Permit #08-4022, Revised 10/13/2021 For resident physicians who wish to serve all or a portion of their residency training in Alaska. Application for Podiatrist License #08-4109, Revised 10/13/2021 Includes application for temporary permit. Application for Locum Tenens Permit #08-4021, Revised 10/13/2021 For medical and osteopathic physicians. Application for Physician Courtesy License #08-4288, Revised 10/13/2021 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 10/13/2021 Application for certified or graduate physician assistants. Physician Assistant Collaborative Plan #08-4226(d), Revised 10/13/2021 Addendum to Collaborative Plan #08-4226(e), Revised 10/13/2021 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 Form used to explain and document "Yes" answer(s) to Professional Fitness questions Letter of Explanation, #08-4752, Revised 9/1/2020 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 Agreement Renewal Collaborative Agreement Renewal Form (08-0079a) Instructions for Sponsor Physician Recommendation Form Sponsor Physician Recommendation Form (08-0078a) 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. Renewal applications will be available no later than December 1, 2020, in accordance with AS 08.01.050. 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 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 Revised 10/2010 Medical Board Change of Address #08-4011, Revised 02/09/12 Physician/Pharmacist Cooperative Practice Agreement 08-4354. Revised 09/2006 Authorization for Prescriptive Authority/Physician Assistant - Certified #08-0017, Revised 09/15/07 Licensing Staff Contact Information Physicians whose last name begins with the letters A through I, O through R 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 T and Paramedics may contact: Licensing Examiner: Jacob Olsen Phone: (907) 465-2566 Email: jacob.olsen@alaska.gov Physicians whose last name begins with the letters U through Z may contact: Natalie Norberg Phone: (907) 465-6243 Email: natalie.norberg@alaska.gov Medical licensing general contact: Phone: (907) 269-8163 Email: medicalboard@alaska.gov