12 AAC 16.031. Application for temporary permit for locum tenens practice

(a) A person applying for a temporary permit for locum tenens practice must meet the applicable requirements of AS 08.20.163 and this section, including passing the state chiropractic examination described in 12 AAC 16.130.

(b) An applicant applying for a temporary permit for locum tenens practice under AS 08.20.163 (b)(1) and this section shall submit

(1) a completed application on a form provided by the department;

(2) the applicable fees established in 12 AAC 02.150;

(3) official college transcripts showing that the applicant meets the education requirements of AS 08.20.120 (a)(2) - (4); and

(4) a certified copy of the applicant's grade transcript from the National Board of Chiropractic Examiners showing that the applicant has successfully passed the applicable national examinations described in 12 AAC 16.037.

(c) An applicant applying for a temporary permit for locum tenens practice under AS 08.20.163 (b)(2) and this section shall submit

(1) a completed application on a form provided by the department;

(2) the applicable fees established in 12 AAC 02.150;

(3) official college transcripts showing that the applicant meets the education requirements of AS 08.20.l63(b)(2)(C) and (D);

(4) a certified copy of the applicant's grade transcript from the National Board of Chiropractic Examiners showing that the applicant has successfully passed the examinations described in AS 08.20.l63(b)(2)(D) and (E);

(5) verification of practice showing that the applicant meets the requirements of AS 08.20.163 (b)(2)(B);

(6) verification of the applicant's licensure status and complete information regarding any disciplinary action or investigation taken or pending, sent directly to the department from all licensing jurisdictions where the applicant holds or has ever held a chiropractic license;

(7) a notarized, sworn statement by the applicant that the applicant has not been, within the five years preceding the date of application, the subject of an unresolved review or an adverse decision based upon a complaint, investigation, review procedure, or disciplinary proceeding undertaken by a state, territorial, local, or federal chiropractic licensing jurisdiction, chiropractic society, or law enforcement agency that relates to criminal or fraudulent activity, chiropractic malpractice, or negligent chiropractic care and that adversely reflects on ability or competence to engage in the practice of chiropractic or the safety or well-being of patients; and

(8) a notarized, sworn statement by the chiropractor licensed in this state for whom the applicant will substitute, including the dates of the substitute practice and the date that the chiropractor licensed in this state will resume practice.

History: Eff. 1/6/2002, Register 161

Authority: AS 08.20.055

AS 08.20.120

AS 08.20.163

AS 08.20.170

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