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ARIZONA MEDICAL BOARD (Arizona Medical Board)

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File type: PDF

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T:\Licensing\New License Applications and forms\Misc Applications\Dispensing Registration\Revised 2018\03.19.2018
ARIZONA MEDICAL BOARD
DISPENSING PHYSICIAN INITIAL REGISTRATION
AND ANNUAL RENEWAL FORM
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
www.azmd.gov
Initial Registration Fee $200 (per physician)
Renewal Registration Fee $150 (per physician)
Last Name:Initial:First Name:
License Number: Specialty:
· Please list below ALL locations where you will be dispensing prescription drugs, devices and controlled substances.
· For each location, place a check mark next to the descriptions of the prescription items which will be dispensed from that location.
· Include a copy of your DEA license if you are requesting dispensing of controlled substances at any location.
PLEASE NOTE
A separate DEA license must be submitted for EACH location where controlled substances will be dispensed and must
be kept current during the registration period.
PRIMARY PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
I am including a second page listing additional locations
Make checks or money orders payable to Arizona Medical Board.
If you wish to pay by payment card, please complete the attached Payment Card Authorization Form
Physician Signature: Date:
T:\Licensing\New License Applications and forms\Misc Applications\Dispensing Registration\Revised 2018\03.19.2018
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
ADDITIONAL PRACTICE LOCATION:
Phone: Fax:
Zip:State:City:Address:
DEA# for this location:
Email:
Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V Drugs
Prescription-Only Drugs Prescription Devices Nubain
T:\Licensing\New License Applications and forms\Misc Applications\Dispensing Registration\Revised 2018\03.19.2018
Arizona Medical Board
PAYMENT CARD AUTHORIZATION
DISPENSING
Name as Shown on Payment Card:
Expiration Date:
AmexMastercardVisa
Type of Card:
Payment for: License #:
(Physician Name)
Billing Address of Cardholder:
(Required)
Phone Number of Cardholder:
Zip:State:City:
Zip:State:City:
(If different from billing address)
Mailing Address of Cardholder:
(Required)
Date:
(Required)
Initial Registration Fee $200 (per physician)
Renewal Registration Fee $150 (per physician)
Mail to: Arizona Medical Board
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
The Arizona Medical Board will only accept credit card payment via mail (USPS, FedEx, UPS, or any
other mail carrier). Any credit card information received via any other method will not be
processed and will be destroyed.
Please complete and return this form with your dispensing registration and all necessary
documents. Return the application and payment form (credit card form, check or money order) to
the address listed below.
Cardholder Signature:
Card Number:
(MM-YY)
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ARIZONA MEDICAL BOARD (Arizona Medical Board)

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Completed 20 July 2020

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