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ARIZONA BOARD OF OSTEOPATHIC EXAMINERS IN MEDICINE AND (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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03/2019
Page 1
Permit
Number: __________________ Issued Date: __________________ Effective Date: __________________ End Date: __________________
(For Board Use Only - Do Not Write Above This Line)
ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
IN MEDICINE AND SURGERY
1740 W. Adams Street, Suite 2410
Phoenix, AZ 85007
PH: 480-657-7703 | FX: 480-657-7715
www.azdo.gov | questions@azdo.gov
ARIZONA OSTEOPATHIC POSTGRADUATE TRAINING PERMIT APPLICATION
(Internship-Residency-Fellowship)
Fee: $50.00 per Permit
For new D.O. trainees who do not currently have an active permit for the program listed in Section 1 or whose
permit has expired. If you
currently hold an active permit, please use the OSTEOPATHIC POSTGRADUATE TRAINING RENEWAL APPLICATION form.
In accordance with A.R.S. § 41-1030 The Board is required to notify you of the following:
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically
authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for
imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically
authorizes the requirement or condition.
D. Thi
s section may be enforced in a private civil action and relief may be awarded against the state. The court may award
reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against
the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary
action or dismissal pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
SECTION 1: TO BE COMPLETED BY NEW APPLICANTS
A. IDENTIFIC
ATION and CONTACT NFORMATION
Applica
nt Name (Last, First, Middle): ____________________________________________________________________
Other names used: _________________________________________________________________________________
Attach copies of all legal documentation showing name changes (i.e.: marriage certificate, divorce decree)
Date of Birth (Required): _________________________ SSN (Required): _____________________________________
Reside
ntial address while in Arizona OR current address:
Address: ______________________________________________________________________________________
City: ____________________________________________________ State: __________ Zip: __________________
Phone: ____________________________ Email (required): ____________________________________________
FOR BOARD USE ONLY
03/2019
Page 2
B. ARIZONA PROGRAM INFORMATION
Name of Training Program/Facility: _____________________________________________________________________
Primary Specialty Field: ___________________________________________________________________________
This is an: Internship Residency Fellowship
C. E
DUCATION HISTORY
You must submit Form No. 1 to your Osteopathic College for verification.
College of Osteopathic Medicine (COM) from which you graduated:
COM Name: _________________________________________________________________________________________
City/State: ___________________________________________________________________________________________
Graduation Date: (MM/DD/YYYY) _________/_________/________________
D. NATIONAL MEDICAL EXAMS
List the national medical examinations you passed and dates. You must submit either a photocopy or original
transcript of your COMLEX Score Report to date and/or USMLE Score Report, or a legible print screen of your View
Scores page from NBOME’s website.
Name of Exam / Part or Level
Date Passed
E. PO
STGRADUATE TRAINING HISTORY
In the box below, please list the internship and residency program(s) in which you have participated, regardless of
completion (if any). You must submit Form No. 2 to each program for verification.
1.
Program Name:
Complete Address:
Specialty Area:
2.
Program Name:
Complete Address:
Specialty Area:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
3.
Program Name:
Complete Address:
Specialty Area:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
03/2019
Page 3
D.O. POSTGRADUATE TRAINING PROFESSIONAL CONDUCT HISTORY QUESTIONNAIRE
Appli
cant Full Name: _____________________________________________________________________________
Name of Program/Facility & Specialty: ________________________________________________________________
F. PROFESSIONAL CONDUCT HISTORY (to be completed by applicant)
FAILURE TO PROPERLY ANSWER THE QUESTIONS BELOW MAY RESULT IN BOARD DISCIPLINARY ACTION OR DENIAL.
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a
separate blank sheet of paper
. As appropriate, attach copies of documents from hospitals, programs, State
Boards, courts and law enforcement agencies confirming your explanation.
YES
NO
1. Have you ever been arrested for, charged with or convicted of any felony, or any misdemeanor? You must
answer “yes” even if the offense occurred outside of Arizona, the case has not yet been adjudicated, you
completed a diversion program, you received a suspended sentence or probation, the convictions were dismissed
or set aside, your sentence was commuted, the records were expunged, your civil rights were restored or you
received a pardon.
2. Have you had any disciplinary or adverse action imposed against any professional license, or were you denied
a professional license, or have you entered into any consent agreement, stipulated order, or settlement with any
regulatory board; OR have you been notified of any complaints or investigations against your license that have
not yet been resolved?
3. Has your DEA permit or prescription permit issued by any regulatory board been denied, restricted,
suspended, lost, or had any other adverse action taken against it, OR have you been notified of any complaints or
investigations against your authority to prescribe that have not yet been resolved?
4. Has any award, settlement, or payment of any kind been made by you or on your behalf to resolve a civil suit
or malpractice claim involving your practice
even if it was not required to be reported to the National Practitioner
Data Bank; OR have you been notified that any such suit or claim is pending?
5. Have your hospital privileges or health care program affiliations been denied, restricted, lost, suspended or
modified, or subjected to any other adverse action even if that action was not required to be reported to the
National Practitioner Data Bank; OR
have you been notified of any complaints against or reviews of your
privileges or affiliations that have not yet been resolved?
6. During an internship, residency or fellowship program were you placed on probation, had your privileges
restricted or
suspended, terminated from the program or had any other adverse action taken against your
participation even if that action was not required to be reported to the National Practitioner Data Bank?
G. PROFESSIONAL CONDUCT HISTORY - CONFIDENTIAL QUESTIONNAIRE
I decla
re and attest that I am the applicant and the person named in this application and in all materials submitted in support of
this application, that all facts stated herein as well as any facts stated on any separate sheets attached hereto are true, complete
and correct. I understand any misrepresentation, including omission of information, may result in an unprofessional conduct
action against this permit or any subsequent application for licensure.
Appli
cant’s Signature: ____________________________________________________ Date:_________________________
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams St., Ste 2410, Phoenix, AZ 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
____________________________________________________________________________________________________________________________________
If you answer “yes” to either of the following questions, you must submit a detailed written narrative
statement concerning matter(s) including the name of the healthcare providers and treatment centers
where you were treated along with the discharge summary of your treatment and progress. If you are
currently participating or have participated in a confidential agreement or order in a program for the
treatment and rehabilitation of doctors of osteopathic medicine impaired by alcohol, drug abuse or for
other issues, please submit a copy of the agreement/order along with compliance reports from the state
monitoring programs.
YES
NO
1. Have you been diagnosed with or developed initial or worsening symptoms of a condition which did or may
impair or limit your ability to safely practice medicine?
2. Have you entered into a diversion program for evaluation, treatment or monitoring for substance abuse or
dependency or for correction of communication or boundary issues, in lieu of or as a condition of resolving a
matter before
a regulatory board, criminal or civil court; OR have you been notified that such action is pending?
You must answer “yes” even if you received a pardon, the convictions were set aside, the records were
expunged, your civil rights were restored and whether or not the sentence was imposed or suspended.
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03/2019
Page 4
SECTION 2: TO BE COMPLETED BY PROGRAM DIRECTOR
Section 2A must be completed by your program director.
INTERNSHIP-RESIDENCY-FELLOWSHIP PROGRAM CERTIFICATION
A. Full Name of Training Program: ______________________________________________________________________
Address: ___________________________________________________________________________________________
Address: ___________________________________________________________________________________________
City _________________________________________________________ State _________ Zip ___________________
Phone Number: ______________________ Email Address: ________________________________________________
Prog
ram Accredited by: AOA ACGME Dual Program No.: ___________________________
This
is an: Internship Residency Fellowship
Primary Field: ___________________________________________________
This
application for permit is for (dates): ______/______/_________ to ______/______/_________ (one year maximum.)
Pleas
e list the hospitals/facilities at which this intern, resident, or fellow will be working in Arizona:
1. ____________________________
____________________ 3. ______________________________________________
2. ________________________________________________ 4. ______________________________________________
Name Signed: ______________________________________________ Date: ____________________________
Name Printed: ________________________________________ Title: ________________________________________
B. Rotation Applicants Only: Have the accredited Arizona hospital/program where you are doing your rotation
complete this section.
ARIZONA CERTIFICATION FOR DOCTORS FROM OUT-OF-STATE PROGRAMS
TO BE COMPLETED BY ARIZONA HOSPITAL/PROGRAM PERSONNEL:
Contact Name: ______________________________________________________
Name and Address of Hospital/Program: ______________________________________________________
______________________________________________________
Phone Number: ______________________________________________________
Email Address: ______________________________________________________
Program Accredited by: AOA ACGME
Dual Program No.: ____________________
Authorizing Signature: _____________________________________________________________________
Name Printed: _____________________________________ Title: _________________________________
Date of Rotation From: ________ / ________ / ___________ to ________ / ________ / ___________
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03/2019
Page 5
Form No. 1: PROFESSIONAL EDUCATION VERIFICATION
In applying for a PGT permit in Arizona, the Arizona Board of Osteopathic Examiners requires this form be completed by the Dean
or the Registrar of the osteopathic medical school from which you graduated. This is authorization to release any information in
your files of record, favorable or otherwise, DIRECTLY to the ARIZONA BOARD OF OSTEOPATHIC EXAMINERS, 1740 W. Adams
St., Ste 2410, Phoenix, Arizona 85007.
App
licant Name: _________________________________________________________, D.O. Last 4 digits of SSN: ______________
Sig
nature _____________________________________________________ Date (Month/Day/Year)__________________________
_____________________________________________________________________________
THIS SECTION TO BE COMPLETED BY AN OFFICIAL OF THE OSTEOPATHIC MEDICAL SCHOOL
Thi
s certifies that __________________________________________________________________________ , D.O.
(Name of Applicant)
was enrolled in: ___________________________________________________________________________________________
(
Name of College of Osteopathic of Medicine (COM))
_____
_____________________________________________________________________________________
(Location – City/State)
The undersigned further certifies that the records of this institution show that the
applicant was granted an Osteopathic Medical
Degree by the above named COM on: _____________________________ Date (Month/Day/Year)
COMMENTS: ________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Signature: __________________________________________________________________ Date: ______________________________________
Name Typed or Printed: _________________________________________________ Title: _____________________________________________
Address: ____________________________________________________________________________ Phone No.: ________________________
City/State/Zip: _____________________________________________________________________ Fax No.: __________________________
Contact person, if different than above: _____________________________________________________________________________________
Email: _________________________________________________________________________________________________________________
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Completed form may be emailed or faxed with coversheet to the Board office
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
______________________________________________________________________________________________________________________________________________________________
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03/2019
Page 6
Form No. 2: POSTGRADUATE TRAINING VERIFICATION
FOR APPLICANT: Make as many copies as needed. Mail or fax this form to the program director of each postgraduate training (PGT) program in which you
participated regardless of completion. This completed form is a requirement when applying for a postgraduate training permit in Arizona. Your signature below
is authorization to release any information about you in your PGT program’s files of record, favorable or otherwise DIRECTLY to the Arizona Board of Osteopathic
Examiners in Medicine and Surgery.
Applicant Name: ___________________________________________________________________________________________, D.O.
Sign
ature _____________________________________________________________________ Date (Month/Day/Year) ___________________________________
THIS SECTION TO BE COMPLETED BY PROGRAM DIRECTOR
FOR PGT PROGRAM DIRECTOR: The above named individual has applied for a postgraduate training permit in Arizona and has stated that he/she has
participated in a PGT program at your facility. He/she is required to submit this form to you for completion. Therefore, please complete this form and return it to
our office at the address above.
1. Important – Program Participation: Please report internships, residencies and fellowships separately. Please report incomplete postgraduate years (PGY)
separately from those successfully completed. If the postgraduate year is currently in progress, report the expected completion date in the “To” field.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
Fro
m: __________/__________/_________ To:__________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Y
ear(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
Fro
m: __________/__________/_________ To:__________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Yea
r(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
Fro
m: __________/__________/_________ To:__________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2. The following questions apply to the PGT years stated above. Please check the appropriate response.
a. This program was approved for postgraduate training during this individual’s attendance by: AOA ACGME DUAL
b. D
id this individual ever take a leave of absence or deferment/break from his/her training? Yes No
c. W
as this individual disciplined and/or placed under investigation or on probation? Yes No
d. Did t
his individual participate in a confidential or public diversion program for substance abuse monitoring? Yes No
Please explain below any “Yes” response(s) to the questions above. Use a separate blank sheet of paper if more room is necessary.
3. COM
MENTS: ________________________________________________________________________________________________________________________
_____
_________________________________________________________________________________________________________________________________
Sign
ature: ______________________________________________________________________________ Date: __________________________________________
Name Typed or Printed: ___________________________________________________________________ Title: __________________________________________
Full n
ame of Program or Hospital: __________________________________________________________________________________________________________
Add
ress: ________________________________________________________________________ Phone No.: ____________________________________________
City/
State/Zip: ___________________________________________________________________ Fax No.: ____________________________________________
Cont
act person, if different from above: ______________________________________________ Email: ________________________________________________
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
______________________________________________________________________________________________________________________________________________________________
Internship
Residency
Fellowship
Internship
Residency
Fellowship
Internship
Residency
Fellowship
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Completed form may be emailed or faxed with coversheet to the Board office
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03/2019
Page 7
Arizona Board of Osteopathic Examiners Postgraduate Training Application
MALPRACTICE CLAIM / SUIT QUESTIONNAIRE
Complete the information below for each instance of any award, settlement or payment of any kind either made by you or on your
behalf to resolve a civil suit or malpractice claim involving your practice even if it was not required to be reported to the National
Practitioner Data Bank, OR if you have been notified that any such suit or claim is pending. Duplicate this form as necessary.
1. Ap
plicant’s name: ____________________________________________________________________________
2. Na
me of patient: ____________________________________________________________________________
Last name First name Middle name/initial
3. Dat
e of occurrence: ________________________________
4. Lo
cation of occurrence: _______________________________________________________________________
Name of hospital/office/clinic) City / State
5. C
urrent status of suit/claim: Pending Settled
If
settled, was it settled: in court out of court Date of settlement: ______ /______ /______
6. Total amount of settlement/award: ________________ Amount attributable to you_________________
7. Na
me of your insurance company: __________________________________________________________
8. Has
this case been investigated or reviewed by any State Board? No Yes Pending
If
Yes or Pending, name of Board: ________________________________________________________
Wh
at was the outcome? Please include a copy of the final disposition:
_______________________________________________________________________________
9. On
a separate sheet of paper, in your own words, briefly describe the claim/suit, and your involvement.
Attaching the NPDB description is not
an acceptable response.
10. At
tach the following documents to this form. Your application will not be decided upon until all of the
following documents have been received:
a. plaintiff’s complaint or claim to insurer;
b. settlement agreement, court order, or dismissal letter (if case has concluded); and
c. Board resolution after investigation of case (if case has concluded).
____
______________________________________________________ __________________________
Signature of applicant Date signed
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03/2019
Page 8
ARIZONA STATEMENT OF CITIZENSHIP
AND ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Permit
Arizona Board of Osteopathic Examiners in Medicine & Surgery
Tit
le IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621, provides
that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and
sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are
eligible to receive state or local public benefits. With certain exceptions, a professional license and commercial license issued by a
State agency is a State public benefit.
Ari
zona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation to the
license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under federal law.
Dir
ections: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals must also
complete Section III.
Sub
mit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S.
National Status or Alien Status" with your application for license or renewal. If the document you submit does not contain a
photograph, you must also provide a government issued document that contains your photograph. You must submit supporting
legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your current legal name.
SECTION I – APPLICANT INFORMATION
APP
LICANT'S NAME (Print or type) _____________________________________________________
TYPE OF APPLICATION (Check one) INITIAL APPLICATION RENEWAL
TYP
E OF LICENSE/PERMIT (Check one) DO PGT Locum Tenens
SECTION II – CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are
you a citizen or national of the United States? Yes No
If Yes, indicate place of birth:
Cit
y ______________________________ State (or equivalent) _________ Country or Territory _______________________
If yo
u answered Yes, 1) Attach a legible copy of one or more document(s) from the attached
"Evidence of U.S. Citizenship, U.S. National Status or Alien Status" page.
Name of document ___________________________________________
2) Go t
o Section IV.
If yo
u answered No, you must complete Section III and IV.
SECTION III – ALIEN STATUS DECLARATION
To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropriate box. Attach a legible copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S. National
Status or Alien Status". Name of document provided _____________________________________________________________.
03/2019
Page 9
Qualified Alien Status (8 U.S.C. §§ 1621(a)(1),-1641(b) and (c))
1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
2. An alien who is granted asylum under Section 208 of the INA.
3. A refugee admitted to the United States under Section 207 of the INA.
4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.
5. An alien whose deportation is being withheld under Section 243(h) of the INA.
6. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
7. An alien who is a Cuban/Haitian entrant.
8. An a
lien who has or whose child or child's parent is a "battered alien" or an alien subject to extreme cruelty in the
United States.
No
nimmigrant Status (8 U.S.C. § 1621(a)(2))
9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.C § 1101 et seq.] Nonimmigrants are persons who have
temporary status for a specific purpose. See 8 U.S.C § 1101(a)(15).
Ali
en Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA
Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
11. A nonimmigrant whose visa for entry is related to employment in the United States or
12. A citizen of a freely associated state, if section 141 of the applicable compact of free association approved in Public Law 99-
239 or 99-658 (or a successor provision) is in effect (Freely Associated States include the Republic of the Marshall Islands, Republic of
Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 et seq.);
13. A foreign national not physically present in the United States.
Otherwise Lawfully Present
14. A person not described in categories 1-13 who is otherwise lawfully present in the United States. PLEASE NOTE: The
federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons who fall into this category ineligible
for licensure. See 8 U.S.C. § 1621(a).
SECTION IV - DECLARATION
All applicants must complete this section.
I de
clare under penalty of perjury under the laws of the state of Arizona that the answers and evidence I have given are true and
correct to the best of my knowledge.
APPLICANT'S SIGNATURE
TODAY'S DATE
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03/2019
Page 10
EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS OR ALIEN STATUS
You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your
current legal name.
Evidence showing authorized presence in the United State includes the following:
1. An Arizona driver license issued after 1996 or an Arizona non-operating identification license.
2. A driver license issued by a state that verifies lawful presence in the United States.
3. A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (on
or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa or the Northern
Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local time). A birth certificate must be
accompanied by a copy of a current government issued ID.
4. A United States certificate of birth abroad.
5. A United States passport. ***Passport must be signed***
6. A foreign passport with a United States visa.
7. An I-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization document or refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or Bureau of Indian Affairs affidavit of birth.
13. Any other license that is issued by the federal government, any other state government, an agency of this state or a political
subdivision of this state that requires proof of citizenship or lawful alien status before issuing the license.
03/2019
Page 11
CREDIT CARD PAYMENT FORM
Name
of Physician: ____________________________________________, D.O. License No. __________________
Item/
Service Requested:_________________________________________ Amount $ ___________________
We do not accept credit card information by fax or email. Payment can be mailed or called in over the phone.
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | www.azdo.gov
_____________________________________________________________________________________________________________________________________________________
Name as Shown on Payment Card: ________________________________________________________________
Billing Address: (Required)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: __________ Zip: _________________
Phone Number of Card Holder: (Required) _________________________________________________________
Mailing Address (Required if different from billing address)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: _________ Zip: __________________
Phone Number of Card Holder: (Required) _________________________________________________________
Signature of Cardholder: _____________________________________________________ Date: __________________
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Type of Card: Visa MasterCard American Express
Visa or MasterCard #: _________________
- _________________ - _________________ - _________________
American Express #: _________________ - ________________________ - _________________
Expiration Date: ________________________
(MM/YY)
Note: The Board shreds this form after payment has been authorized by your credit card company
03/2019
Page 12
Po
stgraduate Training Permit Application
Processing Overview
YO
U OR YOUR RESIDENCY COORDINATOR SUBMITTED YOUR
POSTGRADUATE TRAINING PERMIT APPLICATION,
WHAT HAPPENS NEXT?
AD
MINISTRATIVE COMPLETENESS/DEFICIENCY LETTER
: Within about fourteen (14) days after your application has been
received, staff will email you a list of the missing or incomplete documentation needed to complete your application. Your
residency coordinator will be copied on the email. However, you are responsible to submit the verification forms to your College
of Osteopathic Medicine and any postgraduate training programs in which you have participated regardless of completion. This
does not include an academic year you have not yet started. Contact your residency coordinator if you need assistance. You may
also email or call the Board’s licensing division.
If a
ll the documents needed to complete your application have been received, you will not receive an email.
ADMINISTRATIVELY COMPLETE
: Your application is complete when all the required documentation has been received at the
Board’s office. At this point your application moves to substantive review.
SUB
STANTIVE REVIEW
: This stage of the application process is the evaluation of all answers, documents and verifications
collected and the decision whether they demonstrate you are qualified for a postgraduate training permit. You may be required
to appear before the Board at a regularly scheduled Board meeting for a decision on your application.
ISSU
ANCE OF YOUR PERMIT
: If at the conclusion of the substantive review your permit is approved, it will be issued within three
(3) business days. A letter will be sent by email to your residency coordinator. This letter provides your permit number, your
name and the effective dates of the permit along with other important information. It may also list other residents in your
program. You will be copied on the email, or if the letter has more than one resident listed you will be blind-copied.
Yo
u can check on the status of your permit the Friday after it is issued by going to www.azdo.gov > For DOs > Postgraduate
Permits and clicking on the permit list for the newest academic year listed. If a permit is issued late on Thursday or on Friday,
the list on the website will not show your permit until the following Friday afternoon.
RE
NEWING YOUR PERMIT
: Unless you are doing a short rotation of four (4) months or less, your permit is valid for one year and
must be renewed each year you are enrolled in an Arizona postgraduate training program.
In m
ost instances, your residency coordinator will register you for renewal online starting March 1
of each year. However, you
will have some paperwork to fill out to complete the process. If your residency coordinator has not provided you with the
document(s) you need to complete for your renewal, please contact him/her at least sixty (60) days in advance of your next
academic year’s start date. You may also contact the Board’s licensing division for assistance.
Ar
izona Revised Statutes and Rules for osteopathic licensure can be found on our website at www.azdo.gov
> Statute and Rules.
As a permit holder in the supervised setting of your accredited postgraduate training program, you will be subject to all state and
local laws and regulations pertaining to public health and subject to all the same duties and obligations and authorized to
exercise all the same rights and privileges possessed by physicians and surgeons of other complete schools of medicine in the
practice of their profession per A.R.S. § 32-1852.
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ARIZONA BOARD OF OSTEOPATHIC EXAMINERS IN MEDICINE AND (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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Completed 20 July 2020

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