Alternate Entry Path Subspecialty Plan

ALTERNATE ENTRY PATH SUBSPECIALTY PLAN
Request for Subspecialty Prospective Approval

This form must be accompanied by a letter of support (on institutional letterhead), signed and dated by the program director and chair of the anesthesiology department. The letter must provide a detailed description of the physician’s planned experiences for the year. The plan must be comprehensive and include all objectives for the academic year. The application fee of $1,000.00 must also be submitted with this information.

Complete the form below and upload the supporting documents.
Mail the $1,000 check for the application fee to:
ABA Secretary
The American Board of Anesthesiology
4200 Six Forks Road, Suite 1100
Raleigh, NC 27609
Download, print and complete this mail-in form to send with your check.

Program Information

Sponsoring Program Name*

Program City and State*

RRC Number*

Department Chair*

Physician Applicant Information

First Name*	Middle Name

Last Name*

Gender*

Male

Female

Nonbinary

SSN*

Birth Date*

Country of Birth *

Program where Alternate Entry Pathway in Anesthesiology was completed*

Dates of Alternate Pathway in Anesthesiology Program*

Date ABA Certification Awarded*

Date physician will enroll in your program*

*An up-to-date copy of the physician's Curriculum Vitae must be submitted with this request

One-Year Application

Please indicate below the experiences, including dates, planned for the subspecialty physician:*

UPLOAD THE FOLLOWING DOCUMENTS

All requests for prospective approval for an ABA-certified anesthesiologist to participate in the AEP Fellowship program must be accompanied by the following documentation:

Cover letter (on institutional letterhead), signed and dated, by the chair of the program director and chair of the anesthesiology fellowship department that sponsors the physician*

Detailed plan of the physician's one-year experience*

Up-to-date copy of the physician's Cirriculum Vitae*

Verification of an active, unrestricted medical license in one state of the United States or Canada.*