Physician Supervision of 15 ATs or More – Alabama Board of Athletic Trainers

Physician Name:*

Are you able to supervise more than 15 Athletic Trainers?*YesNo

Are you within 150 miles of each Athletic Trainer you supervise?*YesNo

A list of athletic trainers that you are currently supervising can be obtained by contacting this Board (email: athletictrainer@alstateboard.com).*

Please provide information relevant to your ability to supervise more than 15 Athletic Trainers including your educational preparation, experience, specialty, and other qualifications.*

ATTESTATION

By Selecting this checkbox, I understand that I, the physician, am the ultimate authority for the management of athletic training services. By signing this consent form, I affirm I can adequately supervise Athletic Trainers to assist or carry out any instructions or procedures that I determine to be warranted or necessary in the practice of athletic training services. I also affirm that I have read Alabama Board of Athletic Trainers’ § 34-40-2 Code of Ala. 1975 and Chapter 140-X-8.05 Admn. Code, and I am willing, able, and capable of supervising more than 15 Athletic Trainers. Please note that registration to supervise more than 15 athletic trainers is required annually. Subsequent approval of this request by the Board of Athletic Trainers and Board of Medical Examiners will expire December 31 of each year.

Signature:*

Address:*

City:*

State:*

Zip Code:*

Contact Phone Number:*

Email:*

Date:*

NPI Number:*

Please attach list and practice location of athletic trainers under your supervision for the upcoming licensure year that will begin January 1, of each year. Also, please download and complete the List of Athletic Trainers form link below:*

List of Trainers

Attach the List of Athletic Trainers form here. Please attach additional forms as needed.*

Submit