al-al-6a7cdd9b0011fc86c9e74a28: 540-X-8-.12 — Limitations Upon Utilization Of Certified Registered Nurse Practitioners

APA-1 TRANSMITTAL SHEET FOR NOTICE OF INTENDED ACTION Control No.: 540 Department or Agency: ALABAMA BOARD OF MEDICAL EXAMINERS Rule No.: 540-X-8-.12 Limitations Upon Utilization Of Certified Registered Rule Title: Nurse Practitioners Intended Action: Amend Would the absence of the proposed rule significantly harm or Yes endanger the public health, welfare, or safety? Is there a reasonable relationship between the state’s police power and the protection of the public health, safety, or welfare? Yes that could adequately protect the public? of regulation available No Does the proposed rule have the effect of directly or indirectly No increasing the costs of any goods or services involved? To what degree?: N/A Is the increase in cost more harmful to the public than the harm NA that might result from the absence of the proposed rule? Are all facets of the rule-making process designed solely for the purpose of, and so they have, as their primary effect, the Yes protection of the public? litigation which the agency is a party to concerning the subject No matter of the proposed rule? Does the proposed rule have an economic impact? No If the proposed rule has an economic impact, the proposed rule is required to be accompanied by a fiscal note prepared in accordance with subsection (f) of Section 41-22-23, Code of Alabama 1975. Certification of Authorized Official with the requirements of Chapter 22, Title 41, Code of Alabama 1975, and that it conforms to all applicable filing requirements of the Administrative Procedure Division of the Legislative Services Agency. Signature of certifying officer Wi iam M. Perkins D William M Perkins R E C ’ D & F I L E Date Thursday, September 17, 2026 ,2 026 S EP 1 7 V C AG EN C Y L E G I L AT IVE S APA-2 ALABAMA BOARD OF MEDICAL EXAMINERS NOTICE OF INTENDED ACTION AGENCY NAME: Alabama Board of Medical Examiners 540-X-8-.12 Limitations Upon Utilization Of RULE NO. & TITLE: Certified Registered Nurse Practitioners INTENDED ACTION: Amend SUBSTANCE OF PROPOSED ACTION: Following issuance of the July 20, 2026, Attorney General’s opinion on the role of the Joint Committee for Advanced Practice Providers regarding recommendations for consideration by the Alabama Board of Nursing and the Alabama Board of Medical Examiners addressing collaborative relationships between physicians and CRNPs and/ or CNMs, the attached rule is proposed to bring the ALBME’s rules into alignment with the opinion. TIME, PLACE AND MANNER OF PRESENTING VIEWS: All interested persons may submit data, views, or arguments concerning the proposed new rule(s) and regulation(s) in writing to: Effie Hawthorne, Office of the General Counsel, Alabama State Board of Medical Examiners, Post Office Box 946, Montgomery, Alabama 36101-0946, by mail or email (publiccomment@albme.gov), until and including November 4, 2026. Persons wishing to submit data, views, or comments in person should contact Effie Hawthorne by telephone (334-833-0171) during the comment period. Copies of proposed rules may be obtained at the Board’s website: www.albme.gov. FINAL DATE FOR COMMENT AND COMPLETION OF NOTICE: Wednesday, November 4, 2026 CONTACT PERSON AT AGENCY: Effie Hawthorne Associate General Counsel publiccomment@albme.gov 334-833-0171 Wi iam M. Perkins William M Perkins (Signature of officer authorized to promulgate and adopt rules or his or her deputy) 540-X-8-.12 Limitations Upon Utilization Of Certified Registered Nurse Practitioners. (1) A physician may enter into collaborative agreements with certified registered nurse practitioners not exceeding a cumulative three hundred and sixty (360) hours (nine FTEs) per week. The physician shall not collaborate with or supervise any combination of certified registered nurse practitioners, certified nurse midwives and/or assistants to physicians exceeding three hundred and sixty (360) hours per week (nine full-time equivalent positions). "One full- time equivalent" (FTE) is herein described as a person/persons collectively working forty hours a week, excluding time on call. (a) A physician collaborating with more than four FTEs per week shall engage in documented quality assurance review with each CRNP every month for six (6) months following the commencement of a collaborative practice with a new CRNP. (b) A physician shall disclose to the Board of Medical Examiners the existence of all collaborative and supervisory agreements to which the physician is a party, including collaborative and supervisory agreements in other states, and shall not be eligible to collaborate with or supervise any combination of certified registered nurse practitioners, certified nurse midwives and/or assistants to physicians exceeding three hundred and sixty (360) hours per week (nine full-time equivalent positions), inclusive of collaborative and supervisory agreements existing in other states. Agreements with an individual certified registered nurse practitioner, certified nurse midwife, and/or assistant to physician in multiple states shall only be counted once for purposes of calculating the total number of full-time equivalent positions (2) Employees of the Alabama Department of Public Health and county health departments are specifically exempt from the requirements of paragraph (1) of this rule. (3) CRNPs practicing under approved limited protocols, specified and approved by the Board of Nursing and the Board of Medical Examiners, may be specifically exempt from the FTE requirements of this rule, or as specified in the limited protocol, as determined by the Board of Nursing and the Board of Medical Examiners. (4) A physician in collaborative practice may request approval from the Joint Committee for additional full-time certified registered nurse practitioner positions, with consideration given 8-.12-1 to the following factors, to ensure that an acceptable standard of care is rendered: (a) availability of the physician (b) practice settings and staffing needs for extended hours of service (c) risk to patients (d) educational preparation, specialty and experience of the parties in the collaborative practice (e) complexity and risk of procedures to be performed. (5) Any certified registered nurse practitioners engaged in practice with a collaborating physician prior to the effective date of this rule, may not be denied approval for continued collaborative practice with that physician based on the ratio established in this rule. (6)(5) A physician in collaboration with CRNP, CNM or supervising Physician Assistant personnel totaling 360 hours per week (nine (9) FTEs) may request a transitional allowance increasing the total weekly hours for the purpose of orientation of the incoming CRNP. The transitional allowance shall not exceed 45 days. The physician shall request the transitional allowance in writing to the Board of Medical Examiners and specify the starting date for this FTE allowance. Author: Alabama Board of Medical Examiners Statutory Authority: Code of Ala. 1975, §§34-21-87, 34-24-53. History: New Rule: Filed June 20, 1996; effective July 26, 1996. Amended: Filed August 25, 2003; effective September 29, 2003. Amended: Filed July 22, 2005; effective August 26, 2005. Amended: Filed July 2, 2015; effective August 6, 2015. Amended: Filed September 20, 2018; effective November 4, 2018. Amended: Filed August 23, 2019; effective October 7, 2019. Amended: Published April 30, 2021; effective June 14, 2021. Amended: Published ______; effective ______. 8-.12-2