BasicMed Doctor Consent

AOPA BasicMed Physician Directory Consent Form

*PLEASE NOTE!* Once you have completed and submitted this form, your listing will not show up immediately in the doctor finder database. We typically get your listing validated and uploaded to the live database within 1-2 business days.

Thank you for your interest in joining the Aircraft Owners and Pilots Association’s public directory of state-licensed physicians who are available to perform BasicMed examinations.

For the Aircraft Owners and Pilots Association (AOPA) to share your information with the public and publish it in our directory, it is important that we receive your consent to do so. AOPA’s use of the information that you provide is not a recommendation or endorsement of you by our association. The information you provide is offered to the public free of charge as a resource to assist pilots in locating nearby physicians.

If corrections are required to any information provided below, or you wish to withdraw this consent, please email [email protected] with your request.

Please acknowledge the following:

Yes, I am a state-licensed physician (see footnote+ below) Yes, I am available to perform BasicMed examinations Yes, I want to be included in AOPA’s publicly available directory of state-licensed physicians willing to perform BasicMed exams. I understand that the information in this directory may be published in print or electronic media, and may also be shared with or otherwise provided to individuals who contact AOPA

Physician Qualifications

The FAA relies on the determination of each State (as well as each territory and possession of the United States) as to which persons it will license as physicians. If the person holds a license as a physician issued by any State, territory, or possession, then they meet the requirement as a state-licensed physician. The FAA notes that all States license medical doctors (M.D.) and doctors of osteopathic medicine (D.O.) as physicians; although Federal and some State laws may permit the licensure of other persons, such as doctors of dental surgery (D.D.S.), as physicians. While the FAA expects that these specialists (e.g., D.D.S., dentist, podiatrist, etc.) who do not also hold an M.D. or D.O. would not have the breadth of training for a BasicMed medical examination, the FAA will rely on each State-licensed physician to determine whether he or she is qualified to conduct the medical examination. Physicians should refer to their State medical licensing authority for further guidance.”FAA Advisory Circular 68-1A, page 7-4, located here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_68-1A.pdf

I consent to AOPA including the following information about me in the directory:

First Name Last Name Practice Name (optional) Street Address City (do not insert zip code - see below for zip code field) State Zip Code Phone Number Email (please include if able)

Please check the required acknowledgement boxes in the first section before continuing.