Physician assistant database request access form - Alabama 2025

1. Click ‘Get Form’ to open the Physician Assistant Database Request Access Form in the editor.
2. Begin by filling out the 'Physician Assistant's Information' section. Enter your first name, last name, Social Security Number (SSN), date of birth (DOB), state board license number, DEA number, QACSC registration number, and email address.
3. Next, complete the 'Facility's Information' section. Provide the facility name, address, city/county, state, phone number, fax number, zip/postal code, and email address.
4. Create a system access password that meets the specified criteria: 6-8 characters including at least one capital letter, one lowercase letter, and one number. Ensure it does not contain dictionary words or names.
5. Select and answer one of the security questions provided for added security verification.
6. Sign the form in the designated area for the Physician Assistant's signature. Ensure you have a notary public witness your signature as required.
7. Finally, prepare to mail the completed form along with a notarized access request form, signed copy of the privacy statement, and a copy of your current driver's license to the address provided.

Start using our platform today to easily fill out your Physician Assistant Database Request Access Form for free!