01/2018
ARIZONA D.O. PUBLIC RECORDS REQUEST FORM
To order, please complete this form and mail, email or fax to the Arizona Board of Osteopathic Examiners in Medicine and Surgery.
If paying by check, you will be invoiced for the cost of the copies. Upon receipt of your check or credit card payment form,
the requested documents will be forwarded. If paying by credit card, please complete the attached Credit Card Payment Form and
mai it to the Board. A receipt for the total amount charged will
be sent with the documents requested.
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Contact Name (please print) Phone Number
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Company Name Fax Number
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Address
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City/State/Zip
Public Records Requested
PLEASE NOTE: All investigative materials (case files) are confidential and will not be made available to the public. Only the final disposition of a case
is public information. Disciplinary actions from the last two (2) years are available for free download at www.azdo.gov in the Recent Board Actions
list. All disciplinary actions are available for free download in the physician’s online professional profile (use Doctor Search). Non-disciplinary
actions for the past five (5) years are available upon written request by email. Please send your request to questions@azdo.gov. Letters of
Concern and Dismissals are no longer part of the public record after five (5) years from date of issuance. Minutes for the past five (5) years are
available for free download at www.azdo.gov. Please see the Public Records Request Notice for further information regarding what is and what is
not public record.
PLEASE CHECK ONE OF THE FOLLOWING:
I want to view public records at the Arizona Board of Osteopathic Examiners in Medicine and Surgery’s office at no cost.
I will arrive between 8 am-Noon Noon-5pm on date: ___________________________________________________
I want to purchase copies of the public records. Copied documents will be emailed to you in PDF format. Copies are $0.25 per page.
REQUIRED: Email address for data transfer: ________________________________________________________________________
Pursuant to A.R.S. § 39-121.03, please complete the following statement:
These records will be used for commercial purposes. non-commercial purposes.
If commercial purpose, you are required to specifically state for what purpose: _____________________________________________________
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The public records described above and which I have requested are to be used solely for the purposes stated above. They will not be used directly
or indirectly for a different purpose other than described above. The information I have provided is true and correct.
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Authorized Signature Date
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
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License Files – List physician’s full name or
license number if known.
Board Meeting Minutes – List meeting dates.
click to sign
signature
click to edit
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