myBama
Tuscaloosa Family Medicine Residency

Fellowship Applications

You will find the appropriate application under the corresponding tab. If you have further questions about the application process, please reach out.

Behavioral Health

Behavioral Health Fellowship Application

Your Information
Name(Required)
Date of Birth(Required)
Address(Required)
Accepted file types: jpg, jpeg, png, Max. file size: 200 MB.
Are you a U.S. citizen?(Required)
Do you require VISA support?(Required)
Please include the name(s) of the institution(s), the location(s), dates attended, and degree(s) earned.
Please list the name of the medical school, location, and dates attended.
Drop files here or
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 200 MB, Max. files: 3.
    Please list residency program(s), location(s), and dates attended.
    Medical License
    State that issued your license
    Medical License Examiners

    Include all scores whether passing or non-passing.

    Submit FLEX, USMLE, or COMLEX scores.

    Part 1 Date Completed
    Part 2 Date Completed
    Part 3 Date Completed
    Drop files here or
    Accepted file types: jpg, jpeg, png, pdf, Max. file size: 200 MB, Max. files: 3.
      Fellowship Application
      Accepted file types: jpg, jpeg, png, pdf, Max. file size: 200 MB.
      Locations and Dates
      Author, Title, Publication, and Date. Please upload a copy of the title page of any listed publication.
      Drop files here or
      Accepted file types: jpg, jpeg, png, pdf, Max. file size: 200 MB, Max. files: 5.
        Occupation, Title, and Dates
        Are you certified by the E.C.F.M.G.?(Required)
        Have you been placed on any form of discipline (e.g., Letter of Concern, Probation, Suspension, Non-Renewal of contract) during your residency training?(Required)
        Have you had your privileges revoked?(Required)
        Have you ever been part of a malpractice complaint?(Required)
        Occupation, Title, and Dates
        References

        We require three letters of recommendation; one from your residency director and two additional letters from other people.

        Rural Practice Required post Fellowship
        I understand that the Behavioral Medicine Fellowship requires the fellow to practice for one year in rural Alabama following the one year fellowship.(Required)
        Dates, Location, and Instructor
        Volunteer or experience other than residency or moonlighting
        Name of Conferences, Dates, and Locations
        Name of Conference, Date, and Location.
        Accepted file types: jpg, jpeg, png, pdf, Max. file size: 200 MB.
        Approval
        I certify that the information given or attached is true, accurate, and complete.(Required)
        Sign your full name; this constitutes an Electronic Signature.
        Emergency Medicine
        Hospitalist
        Obstetrics
        Rural Public Psychiatry