Compliance Forms

Declaration of Compliance

Upon signing the Declaration of Compliance, the licensee is attesting to full compliance with the terms of the Board Order or Consent Agreement. If the licensee is not in full compliance with the board action, they must indicate the areas of non-compliance on the lines provided (i.e., relapse, missed or late calls to the drug testing program, failure to attend the required amount of alcohol drug rehabilitation meetings, etc.).

Alcohol and Drug Rehabilitation Attendance Log

Licensee shall maintain a participation log in an alcohol and drug rehabilitation program, such as A.A., N.A., C.A., or Caduceus as required by order of the board. Substitution of any other specific program must receive prior board approval.

Log of Controlled Substances Prescribed, Administered, Dispensed

The Log of Controlled Substances is to be used by all licensees who are required by order of the State Medical Board to maintain and periodically submit to the board records or logs reflecting their utilization of controlled substances. It is essential that you carefully read and comply with the following instructions, since submission of an inaccurate or incomplete log constitutes a violation of probation and may result in revocation of license.

Physician Assistant Prescribing Log

The Physician Assistant Prescribing Log is to be used by all Physician Assistants who are required by order of the State Medical Board to maintain and periodically submit to the board records or logs reflecting their utilization of controlled substances. It is essential that you carefully read and comply with the following instructions, since submission of an inaccurate or incomplete log constitutes a violation of probation and may result in revocation of license.

Treating Physician Nomination Form

Work Hour Log Form