:: Initial Applications ::

MSP Application

MSP CHECKLIST - Confirm you have met all the following checklist requirements in order to proceed with the application Step 1 / 16

Ready?

Requirement

Information

Yes

I have requested that an official transcript from all nursing program(s), both undergraduate and graduate, be sent to ABN. NOTE: If applying based on a doctorate degree, a copy of the master’s degree transcript is also required.

Transcripts MUST be received directly from the nursing program via an electronic transcript service or the US Postal Service. Faxed transcripts will not be accepted.

Yes

I have requested that proof of my national certification be sent to the ABN.

Certifications MUST be received directly from the certifying agency, via email or the US Post Service. Faxed certifications will not be accepted.

Yes

N/A

For United States Citizens, I am prepared to upload the supporting documentation to complete the Citizenship/Legal Presence portion of the electronic application.

Yes

N/A

For Non-United States Citizens, I am prepared to upload the supporting documentation to prove my citizenship/legal presence.

Yes

Prepared to submit application fees

CRNP or CNM seeking “Eligible for Collaboration” status; No collaborating physician at this time. Fee = $100

CRNP or CNM seeking “Approval”; Collaborating physician included. Fee = $175

CRNA or CNS seeking “Approval”. Fee = $175

Yes

For CRNPs and CNMs who have a collaborating physician: Have you printed, completed, and are ready to upload the Standard Protocol based on your national certification?

To print the document, go to the ABN website under Licensing/Advanced practice Nursing/CRNP or CNM/Standard Protocol. *please choose the protocol that coincides with your national certification*

Yes

For CRNPs and CNMs who have a collaborating physician: Have you printed, completed, and are ready to upload the Quality Assurance Plan?

To print the document, go to the ABN website under Licensing/Advanced practice Nursing/CRNP or CNM/Resources/Collaborative Practice Quality Assurance Plan.

Yes

Has your physician sent Commencement Form to the Board of Medical Examiners?

Available on the Board of Medical Examiners website.

APPLICATION FOR ADVANCED PRACTICE MULTISTATE PRIVILEGE (MSP) Step 2 / 16

Do you currently have an active, non-Alabama RN multistate compact license?

Yes

Have you taken the certification exam?

Yes

DEMOGRAPHICS Step 3 / 16

First Name

Middle or Maiden Name

Last Name

SSN

Date of Birth

Physical Address

Address 1

Address 2

City

State

Zip

Mailing Address

Same as Physical Address

Address 1

Address 2

City

State

Zip

Contact Information

Phone

Alternate Phone

I understand that no one else may complete this application on my behalf and that I am accountable and responsible for the accuracy of any answer or statement on this application and the documents submitted with the application. I affirm that the information on this application and the documents submitted with this application are true and correct. I understand that submission of any false statement or document is grounds for denial, discipline or revocation of my Alabama MSP license.

EDUCATION Step 5 / 16

Degree

Graduation Date

State

City

Zip

Name As It Appears on Transcripts

CERTIFICATION Step 6 / 16

CERTIFICATION DETAILS

Certifying Organization

Specialty

National Certification Number

Certification Start Date

Certification End Date

I have requested the certifying organization to send the Alabama Board of Nursing official verification of my current certification in the specialty listed.

COLLABORATION Step 7 / 16

Do you have a collaborating physician?

Yes

Collaborating Physician: A doctor of medicine or a doctor of osteopathy licensed to practice medicine in Alabama who agrees in writing to practice in collaboration with one or more CRNPs or CNMs.

COLLABORATING PHYSICIAN/PRIMARY PRACTICE SITE Step 8 / 16

Physician’s Name

Note: To select a physician, click on “Search” and search by physician name or license #

Physician License

Specialty

Physician’s Physical Address

Address 2

City

State

Zip

County

Note: This is the physician’s principal practice site as per the information provided by the physician to the Board of Medical Examiners

COLLABORATION – PRACTICE SITE Step 9 / 16

Principal Practice Site Details of Collaborating Physician

Practice Site Name

Practice Site Address

Address2

City

State

Zip

County

Will you be working at additional practice sites, other than the principal practice site above, with this collaborating physician?

Yes

Select Regularity

Full Time

Part Time

Flex/PRN

QUALITY ASSURANCE PLAN Step 12 / 16

I am submitting the following Quality Assurance Plan. The form has been completed and includes the original signatures of the Collaborating Physician and the CRNP/CNM.

PREVIEW Step 14 / 16

E-SIGNATURE Step 15 / 16

I affirm that:

The information recorded on this application concerning any item is true and correct and that I may be required to submit documentation to support my affirmation.

I understand that any false statement is in violation of the Code of Alabama and the Alabama Board of Nursing Administrative Code and constitutes cause for disciplinary action.

I understand I am not authorized to practice as a CRNA until I receive approval from the Alabama Board of Nursing.

I understand that I am obligated to have my certifying agency notify the Alabama Board of Nursing directly of my recertification and that my approval to practice as a CRNA will lapse if my recertification is not received from the certifying agency prior to the expiration of my current certification.

I understand that it is my responsibility to renew my advanced practice approval during the Alabama RN renewal period in odd-numbered years.

I understand that, should I fail to maintain RN licensure in my home state, my Alabama advanced practice approval will lapse.

I affirm that:

The information recorded on this application concerning any item is true and correct and that I may be required to submit documentation to support my affirmation.

I understand that any false statement is in violation of the Code of Alabama and the Alabama Board of Nursing Administrative Code and constitutes cause for disciplinary action.

I understand I am not authorized to practice as a CNS until I receive approval from the Alabama Board of Nursing.

I understand that I am obligated to have my certifying agency notify the Alabama Board of Nursing directly of my recertification and that my approval to practice as a CNS will lapse if my recertification is not received from the certifying agency prior to the expiration of my current certification.

I understand that it is my responsibility to renew my advanced practice approval during the Alabama RN renewal period in odd-numbered years.

I understand that, should I fail to maintain RN licensure in my home state, my Alabama advanced practice approval will lapse.

I affirm that:

The information recorded on this application concerning any item is true and correct and that I may be required to submit documentation to support my affirmation.

I understand that any false statement is in violation of the Code of Alabama and the Alabama Board of Nursing Administrative Code and constitutes cause for disciplinary action.

I understand I am not authorized to practice as a CRNP until I receive approval from the Alabama Board of Nursing.

I understand that it is my responsibility to renew my advanced practice approval during the Alabama RN renewal period in odd-numbered years.

I understand that, should I fail to maintain RN licensure in my home state, my Alabama advanced practice approval will lapse.

I understand that the Collaborating Physician is required to submit the Commencement Form and fee for Commencement of Collaborative Practice to the Alabama Board of Medical Examiners.

I understand that I am obligated to have my certifying agency notify the Alabama Board of Nursing directly of my recertification and that my approval to practice as a CRNP will lapse if my recertification is not received from the certifying agency prior to the expiration of my current certification.

I understand that I am obligated to:

Notify the Alabama Board of Nursing of termination of collaborative practice.

Maintain a copy of my practice protocol at each practice site and on file with the Alabama Board of Nursing

Maintain a copy of my quality assurance plan and on file with the Alabama Board of Nursing.

I affirm that:

the information recorded on this application concerning any item is true and correct and that I may be required to submit documentation to support my affirmation.

I understand that any false statement is in violation of the Code of Alabama and the Alabama Board of Nursing Administrative Code and constitutes cause for disciplinary action.

I understand I am not authorized to practice as a CNM until I receive approval from the Alabama Board of Nursing.

I understand that it is my responsibility to renew my advanced practice approval during the Alabama RN renewal period in odd-numbered years.

I understand that, should I fail to maintain RN licensure in my home state, my Alabama advanced practice approval will lapse.

I understand that the Collaborating Physician is required to submit the Commencement Form and fee for Commencement of Collaborative Practice to the Alabama Board of Medical Examiners.

I understand that I am obligated to have my certifying agency notify the Alabama Board of Nursing directly of my recertification and that my approval to practice as a CNM will lapse if my recertification is not received from the certifying agency prior to the expiration of my current certification.

I understand that I am obligated to:

Notify the Alabama Board of Nursing of termination of collaborative practice.

Maintain a copy of my practice protocol at each practice site and on file with the Alabama Board of Nursing

Maintain a copy of my quality assurance plan and on file with the Alabama Board of Nursing.

Electronic Signature

I agree to the terms and conditions mentioned above.

Note to Nurse Midwives and Nurse Practitioners: Initial approval is reflected by an approval status of “Eligible for Collaboration” and does not entitle the nurse to use the titles “Certified Registered Nurse Practitioner,” “CRNP,” “Certified Nurse Midwife,” and “CNM.” Those titles are reserved only for nurses who are actively engaged in an approved collaboration with a licensed physician. Following initial approval, collaborations may be added using the electronic “Add Collaboration” application located in My Profile.

AFFIRM AND SUBMIT Step 16 / 16

Multistate License Fee

Transaction Fee

Total

Person's Name on Card

Select Debit or Credit Card

Card Type

Card#

Expiration Date (MM/YY)

Security Code

5 Digit Billing Zip code

Note: The Board of Nursing charge, including a convenience fee, will appear on your statement with a description of IGOVSOL*AL Brd Nrsng

Practice Site Name

Mailing Address

City

State

Zip

County

Phone

First Name

Last Name

License #

Name	License #	Select