Alabama Board of Medical Examiners Docket 540-X-8-.22 Proposed Rule

al-al-6a7cde451ff2a30080acb788: 540-X-8-.22 — Requirements For Collaborative Practice By Physicians And Certified Nurse Midwives

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What this rule does

This proposed rule outlines requirements for collaboration between physicians and certified nurse midwives in Alabama, including the necessity for direct communication and oversight. It establishes guidelines for physician availability during patient care, documentation of experience, and conditions for the temporary designation of covering physicians in the absence of the primary collaborating physician.

Plain-language description generated by AI — not the agency’s official summary, which we have not captured for this rule. Read the official text →

The rule, in full

1,672 words as published, September 30, 2026. View the original →

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-.22 Rule Title: Requirements For Collaborative Practice By Physicians And Certified Nurse Midwives Intended Action: Amend Would the absence of the proposed rule significantly harm or endanger the public health, welfare, or safety? Yes Is there a reasonable relationship between the state’s police Yes power and the protection of the public health, safety, or welfare? Is there another, less restrictive method of regulation available that could adequately protect the public? No increasing the costs of any goods or services involved?ndirectly No To what degree?: N/A that might result from the absence of the proposed rule?the harm NA Are all facets of the rule-making process designed solely for the protection of the public?ave, as their primary effect, the Yes Does the proposed action relate to or affect in any manner any 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 accompanied by a fiscal note prepared in accordance with subsection (f) of Section 41-22-23, Code of Alabama 1975. Certification of Authorized Official I certify that the attached proposed rule has been proposed in full compliance conforms to all applicable filing requirements of the Administrative Procedureit Division of the Legislative Services Agency. Signature of certifying officer Wi iam M. Perkins C ’D & F IL E D William M PerkinsR E Date Thursday, September 17, 2026E P 17, 2026 E NC Y LE G ISL A TIV E S VC A G APA-2 ALABAMA BOARD OF MEDICAL EXAMINERS NOTICE OF INTENDED ACTION AGENCY NAME: Alabama Board of Medical Examiners 540-X-8-.22 Requirements For Collaborative RULE NO. & TITLE: Practice By Physicians And Certified Nurse Midwives 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-.22 Requirements For Collaborative Practice By Physicians And Certified Nurse Midwives. (1) The collaborating physician shall: (a) Provide professional medical oversight and direction to the certified nurse midwife. (b) Be readily available for direct communication or by radio, telephone or telecommunications. (c) Be readily available for consultation or referrals of patients from the certified nurse midwife. (d) Be readily available during labor management to provide direct medical intervention and to attend deliveries if needed. (e) Be readily available at each remote practice site. (2) In the event the collaborating physician is not readily available, provisions shall be made for professional medical oversight and direction by a covering physician who is readily available, who is pre-approved by the Board of Medical Examiners, and who is familiar with these rules. The collaborating physician shall certify to the Board of Medical Examiners at least annually that any approved covering physician continues to agree to serve in that capacity and shall inform the Board of Medical Examiners of the termination of a covering physician within ten (10) days of the termination. (3) In the event of an unanticipated, permanent absence of a collaborating physician, a previously approved covering physician may be designated as a temporary collaborating physician for a period of up to sixty (60) days. During the sixty (60) day time period, a new “Notice of Commencement” designating a new collaborating physician should be submitted for approval. (4) The certified nurse midwife's scheduled hours in patient homes, and/or facilities licensed by the Alabama Department of Public Health and facilities certified by the Alabama Department of Public Health are not subject to the required minimum hours for physician presence. (5) The collaborating physician shall: (a) Have no additional requirement for documentation of on- site collaboration when working in the same facility with the Certified Nurse Midwife (CNM). 8-.22-1 (b) Be present for not less than ten percent (10%) of the CNM’s scheduled hours in an approved practice site with a CNM who has less than two (2) years (4,000 hours) of collaborative practice experience:

2. In the collaborating physician’s practice specialty.

(c) Maintain documentation of the CNM’s two (2) years (4,000 hours) of collaborative practice experience for the duration of the collaborative practice and for three (3) years following the termination of the collaborative practice agreement. (d) Visit remote practice sites no less than twice annually. (e) Meet no less than quarterly with the CNM who has more than two (2) years (4,000 hours) of collaborative practice experience. (f) Complete quarterly quality assurance with each CNM. Documentation of any quality assurance review required by this chapter shall be maintained by the collaborating physician for the duration of the collaborative practice and for three years following the termination of the collaborative practice agreement. (g) Allow a pre-approved covering physician to be present in lieu of the collaborating physician. (6) The collaborating physician shall provide notice in writing to the State Board of Medical Examiners of the commencement or termination of a collaborative practice agreement as required by Rule 540-X-8-.18. (7) The Joint Committee may, at its discretion, waive the requirement of written verification of physician availability upon documentation of exceptional circumstances. Employees of state and county health departments are exempt from the requirement of written verification of physician availability. (8) A written standard protocol specific to the specialty practice area of the certified nurse midwife and the specialty practice area of the collaborating physician, approved and signed by both the collaborating physician and the certified nurse midwife shall: (a) Identify all sites where the certified nurse midwife will practice within the collaboration protocol. 8-.22-2 (b) Identify the physician's principal practice site. (c) Be maintained at each practice site and on file with the Board of Nursing and Board of Medical Examiners. (d) Include a formulary of drugs, devices, medical treatments, tests and procedures that may be prescribed, ordered, and implemented by the certified nurse midwife consistent with these rules, and which are appropriate for the collaborative practice setting. (e) Include a pre-determined plan for emergency services. (f) Specify the process by which the certified nurse midwife shall refer a patient to a physician other than the collaborating physician. (g) Specify a plan for quality assurance management with defined quality outcome measures for evaluation of the clinical practice of the certified nurse midwife and include review of a meaningful sample of medical records plus all adverse outcomes. The term "medical records" includes, but is not limited to, electronic medical records. Documentation of quality assurance review shall be readily retrievable, identify records that were selected for review, include a summary of findings, conclusions, and if indicated, recommendations for change. Quality assurance monitoring may be performed by designated personnel, with final results presented to the physician and certified nurse midwife for review. The certified nurse midwife shall maintain a copy of the plan for quality assurance, in a form prescribed by the Board of Nursing, on file with the Board of Nursing. The collaborating physician shall maintain an updated copy of the plan for quality assurance on file with the Board of Medical Examiners. (9) The physician shall maintain independent medical judgment related to the practice of medicine at all times, irrespective of employment structure or business model. (10) Irrespective of the location of the principle practice site and any remote site(s) of the collaboration, all services provided to patients and actions incident to services provided to patients of the collaborative practice shall be deemed to have occurred in the state where the patient is located at the time of service or action incident to the service. The collaborating physician, covering physician, and certified nurse midwife shall comply with all applicable Alabama laws, rules, and regulations pertaining to services and actions incident to services provided to Alabama patients of the collaborative practice. Actions 8-.22-3 incident to services include, but are not limited to, professional medical oversight and direction to the certified nurse midwife regarding Alabama patients, consultation or referral of Alabama patients from the certified nurse midwife, quality assurance review of the medical records of Alabama patients, and maintenance of documentation pursuant to this chapter. The collaborating physician shall maintain all documentation required pursuant to this chapter for the duration of the collaborative practice and for three years following the termination of the collaborative practice agreement. Author: Alabama Board of Medical Examiners Statutory Authority: Code of Ala. 1975, §§34-21-85, 34-24-53. History: New Rule: Filed June 20, 1996; effective July 26, 1996. Repealed and New Rule: Filed August 25, 2003; effective September 29, 2003. Amended: Filed July 22, 2005; effective August 26, 2005. Amended: Filed October 6, 2006; effective November 10, 2006. Amended: Filed February 21, 2008; effective March 27, 2008. Amended: Filed September 24, 2012; effective October 29, 2012. Amended: Filed July 2, 2015; effective August 6, 2015. Amended: Filed January 22, 2018; effective March 8, 2018. Amended: Filed June 19, 2019; effective August 3, 2019. Amended: Published April 30, 2021; effective June 14, 2021. Amended: Published ______; effective ______. 8-.22-4

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