AOPA BasicMed Physician Directory Consent Form
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 contact Amelia Walsh by email at firstname.lastname@example.org, or by telephone at 301.695.2195.
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:
I consent to AOPA including the following information about me in the directory:
Practice Name (optional)
City (do not insert zip code here- see below for zip code field)
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Email Address (please include if able)
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