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ARIZONA MEDICAL BOARD MD IMLCC Supplemental Forms (Arizona Medical Board)

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T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
ARIZONA MEDICAL BOARD
MD IMLCC Supplemental Forms
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Telephone: 480- 551-2700 Toll Free: 877-255-2212
Website: www.azmd.gov;
LicensingReports@azmd.gov
To be completed and signed by the licensee. All questions MUST be answered, even if only to indicate "None" or "N/A".
Page 1 of 2
Practice Address: This is the practice/principal place of your business. The address and phone number provided will appear in
the Medical Directory and on the Board's website. Every physician must have an address available to the public. If only one
address is provided, even if it is your home address, it will be available to the public upon request. If you want your home
address to be listed as your practice address on the Board's website, include the address in the practice address field.
Other Names Used:
Last Name:
Middle Name:
1. First Name:
Personal Information
Address Information
Phone: Fax:
Zip:State:City:Address:
Current Practice Name:
Zip:State:City:Mailing Address:
2.
*Practice address not required for licensure
Mailing Address: If no address is provided, all Board correspondence will be sent to your practice address.
Home Address: You are required to provide a home address, telephone number and email address. Your home address and
telephone number will not be released to the public unless you fail to provide an office address. Your email address will not be
released to the public, but the Board may occasionally send relevant news and information to you via email.
City:
Phone: Mobile:
Zip:State:Home Address:
Primary Email Address:
3.
Same as Practice Address Same as Home Address
AZ License #:
4.
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
Full Name (Print): Signature:
Page 2 of 2
Area of Interest/ABMS Certification
Indicate your area of interest/specialty (present or future, can be updated if needed) and whether you are certified by
the American Board of Medical Specialties (ABMS).
Area of Interest Practicing? ABMS Certified?
Expiration Date
(Or indicate if lifetime certificate)
NoYes NoYes
NoYes NoYes
NoYes NoYes
5.
Training Unit Attestation
6.
Initial Applications - A.R.S. §32-1422(A)(10): Complete a training unit as prescribed by the board relating to the requirements of this chapter and board rules. The
applicant shall submit proof with the application form of having completed the training unit.
Date:
Full Name (print):
I am aware that I am responsible for knowing and adhering to the laws governing the practice of medicine in Arizona. I
declare under penalty of perjury that I have read and completed all four pages of the training unit provided with these
supplemental forms and available on the Board's website.
Signature:
Medical Practice Act Training and Questionnaire included as pages 7-10 of the Supplemental Forms.
ARIZONA MEDICAL BOARD
MD IMLCC Supplemental Forms
Non- Residency Attestation
7.
Pursuant to Arizona Revised Statutes § 41-1080(A), an applicant for licensure must present documentation of citizenship or alien status
prior to receiving a license from the Arizona Medical Board. An exception to this requirement exists for an applicant who meets all of the
following criteria:
(a) The individual is a resident of another state.
(b) The individual holds an equivalent license in that other state and the equivalent license is of the same type being sought in this state.
(c) The individual seeks the Arizona license to comply with this state's licensing laws and not to establish residency in this state.
Initial _______I am exempt from ARS § 41-1080(A) because all of the above criteria apply. I understand that in the event I establish
residency in Arizona in the future and wish to continue to hold an Arizona Medical License, I will be required to submit proof of citizenship
or alien status to the Arizona medical Board, prior to being eligible for licensure.
Date:
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
ARIZONA STATEMENT OF CITIZENSHIP
OR ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Commercial License
Arizona Medical Board
M.D. License Applicants
Title 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.
Arizona 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.
Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or
nationals must also complete Section III.
Submit 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
APPLICANT'S NAME (Print or Type)
INITIAL APPLICATION RENEWAL
TYPE OF APPLICATION (Check one)
MD Initial or Endorsement Application Teaching License
Locum Tenens
Pro bono registration
Post Graduate Training Permit
Education Teaching Permit
1 of 2
SECTION II – CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a citizen or national of the United States?
If you answered
Yes
, 1) Attach a photocopy of a document from the attached list, section A. Documents from List B
also apply to U.S. Citizens, but submission of a List B document does not negate the
requirement to submit a copy of an item from List A.
If you 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 copy of a document from the attached list, section A. Additionally,
submit an item from the attached list section C or other document as evidence of your status.
Qualified Alien Status (8 U.S.C.§§ 1621(a)(1),-1641(b) and (c))
Yes
No
City of Birth:
State (or equivalent):
Country or Territory:
If Yes, indicate place of birth:
Name of document:
2) Go to Section IV.
Name of document provided:
TYPE OF LICENSE/CERTIFICATION (Check one)
OVER
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
Otherwise Lawfully Present
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 alien who has, or whose child or child's parent is a "battered alien" or an alien subject to extreme cruelty
in the United States.
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).
10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA.
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.
14. A person not described in categories 1-13 who is otherwise lawfully present in the United States.
persons who fall into this category ineligible for licensure. See 8 U.S.C. § 1621(a).
Please NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make
2 of 2
SECTION IV - DECLARATION
All applicants must complete this section.
I declare 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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Evidence of U.S. Citizenship, U.S. National Status, or Alien Status
License Application Types: MD Application
You must submit supporting legal documentation (e.g. marriage certificate) if the name on your evidence
is not the same as your current legal name.
Citizens must submit one of the documents in list A. If applicable, citizens shall also submit a document
from list B, but it does not negate the requirement to submit an item from list A. A copy of a government
issued photo ID is required if the proof of legal status does not include a photo.
Non-citizens must provide one item from both lists A and C.
List A (Applicable to both citizens and non-citizens)
1. A notarized copy of a birth certificate
Or
2. A notarized copy of a passport
List B
1. A United States certificate of naturalization.
2. A United States certificate of citizenship.
3. A tribal certificate of Indian blood.
4. A tribal or Bureau of Indian Affairs affidavit of birth.
List C (Applicable to non-citizens only)
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. This must be
accompanied with a statement by the state issuing entity that the state verifies legal status prior to
issuing the license.
3. A foreign passport with a United States Visa.
4. An I-94 form with a photograph.
5. A United States Citizenship and Immigration Services employment authorization document or refugee
travel document.
6. Any other license that is issued by the federal government, any other state government, an agency of
this state or political subdivision of this state that requires proof of citizenship or lawful alien status
before issuing the license.
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
Arizona Medical Board
Medical Practice Act Training and Questionnaire
Directions:
Please read the case studies and general questions along with the correct responses to each of the questions posed. This training module is designed to
increase your awareness of the statutes and rules that govern the practice of medicine in Arizona. When you have read through the material, please sign the
attestation indicating you have done so and that you are aware that the Medical Practice Act contains the statutory obligations you must meet when you
practice medicine in Arizona. Please be advised that you may access the Medical Practice Act and the corresponding rules on the Board's website:
www.azmd.gov
Medical Practice Act Training & Questionnaire
CASE STUDIES (Multiple Choice)
This section illustrates common violations of the MPA by using case scenarios. Each scenario is followed by a multiple-choice question and the answer.
1. Sexual Conduct
Scenario: You and a patient develop mutual feelings for each other during the course of treatment. You begin dating the patient and mutually agree to begin a
sexual relationship. Should you continue to medically treat the patient?
A. Yes. The treatment began before a sexual relationship was developed. Therefore, it is appropriate to continue treating the patient as you were before.
B. Yes. You can maintain a boundary between your personal feelings for the patient and your professional practice.
C. No. The physician-patient relationship must be terminated six months before engaging in sexual conduct.
D. No. A physician should never establish a sexual relationship with a current or former patient.
Answer: C. No. The physician-patient relationship must be terminated six months before engaging in sexual conduct.
A.R.S. 32-1401(27)(z) states that it is unprofessional conduct to engage in sexual conduct with a current patient or with a former patient within six months
after the last medical consultation unless the patient was the licensee's spouse at the time of the contact or, immediately preceding the physician-patient
relationship, was in a dating or engagement relationship with the licensee.
2. Controlled Substances
Scenario: You are experiencing back pain after a weekend spent moving into a new home. You know the appropriate dose of Oxycodone to relieve your pain.
Instead of requesting an appointment with your primary care physician you call in a prescription to the pharmacy for yourself. Are your actions appropriate?
A. No. Regardless of how seemingly obvious the cause of the pain and type of controlled substance needed, it is never appropriate for a physician to
self-prescribe a controlled substance.
B. No. There are alternative over the counter drugs that can provide the same effect.
C. Yes. You had the same back pain in the past and you were previously prescribed the same medication.
D. Yes. You are a licensed physician. You know exactly what medications you need to feel better.
Answer: A. No. Regardless of how seemingly obvious the illness and type of controlled substance needed, it is never appropriate for a physician to self-
prescribe a controlled substance.
A.R.S. 32-1401(27)(g) states that it is unprofessional conduct to use controlled substances except if prescribed by another physician for use
during a prescribed course of treatment.
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
3. Professional Connection
Scenario: Your friend "Bob" wants to open a laser clinic and perform varicose vein removal. Bob is not a licensed doctor in Arizona, but he holds a medical
license in New Mexico. You are confident that Bob has the education and training to safely perform varicose vein removal, even though it is considered to be
the practice of medicine in Arizona. You decide to help Bob out and let him operate his laser clinic under your name. Is this appropriate?
A. Yes. Even though Bob is not licensed in Arizona, he is a doctor and you know he will do a good job.
B. Yes. The clinic operates under your name and you know Bob will call you with any problems.
C. No. Varicose vein removal is considered to be the practice of medicine and Bob is not licensed to practice medicine in Arizona.
D. No. The state where Bob is licensed may have different regulations for operating a laser clinic than Arizona and you can't be sure if Bob's clinic will
meet Arizona regulations.
Answer: C. No. Varicose vein removal is considered to be the practice of medicine and Bob is not licensed to perform medicine in Arizona.
A.R.S. 32-1401(27)(cc) states that it is unprofessional conduct to maintain a professional connection with or lend one's name to enhance or continue the
activities of an illegal practitioner of medicine.
4. False or Fraudulent Statements
Scenario: You are applying for privileges at a hospital and one of the questions asked of you is whether your license has ever been revoked or suspended.
Knowing that the hospital will likely deny you privileges if you answer affirmatively, you opt to knowingly withhold the fact that your license was previously
suspended over 15 years ago. Are your actions justified?
A. Yes. Because your suspension was so long ago, it is likely the hospital will never find out about it.
B. Yes. Ever since you got your license back, you have been a model physician and you have obeyed all laws.
C. No. The hospital will eventually find out and report you to the Board, resulting in more trouble.
D. No. It is never okay to make a false statement when applying for hospital privileges.
Answer: D. No. It is never okay to make a false statement when applying for hospital privileges.
A.R.S. 32-1401(27)(t) states that it is unprofessional conduct to knowingly make any false or fraudulent statement, written or oral, in connection with the
practice of medicine or if applying for privileges or renewing an application for privileges at a health care institution.
5. Financial Interest
Scenario: You are a pain specialist and many of the patients you see benefit from a combination of pain medication and other forms of therapy, such as
physical therapy. In addition to your pain clinic, you are also part owner of an outpatient physical therapy clinic. If you prescribe physical therapy at the clinic
where you are part owner, should you inform the patients that you have a direct financial interest in the clinic?
A. No. Your patients will receive good care at the physical therapy clinic and do not need to know.
B. No. The amount of money you receive from your ownership interest in the clinic is not enough to require you to inform your patients.
C. Yes. You should inform patients of your financial interest and let them know they can receive therapy elsewhere.
D. Yes. You should inform patients of your financial interest, but stress that they will receive the best therapy at your clinic.
Answer: C. Yes. You should inform patients of your financial interest and let them know they can receive therapy elsewhere.
A.R.S. 32-1401(27)(ff) states that it is unprofessional conduct to knowingly fail to disclose to a patient on a form that is prescribed by the board and that is
dated and signed by the patient or guardian acknowledging that the patient or guardian has read and understands that the doctor has a direct financial
interest in a separate diagnostic or treatment agency or in non-routine goods or services that the patient is being prescribed and if the prescribed treatment,
goods or services are available on a competitive basis. This subdivision does not apply to a referral by one doctor of medicine to another doctor of medicine
within a group of doctors of medicine practicing together. A "Notice To Patients" form can be downloaded off the Board's website.
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
6. GENERAL QUESTIONS (True or False)
1. It is acceptable practice for me to prescribe controlled substances to my spouse and family.
(False: A.R.S. 32-1401(27)(h) states that it is unprofessional conduct to prescribe controlled substances to members of the physician's immediate
family.)
2. If a patient requests her medical records, I can provide a copy of the records, not the original.
(True: A.R.S. 12-2297 states that a health care provider shall retain the original or copies of the medical records.)
3. If I don't provide the Arizona Medical Board with an office address, the Board can give the public my home address.
(True: A.R.S. 32-3801 states that a professional's residential address and residential telephone number or numbers maintained by the Board are
not available to the public unless they are the only address and numbers of record.)
4. I can ask my medical assistant to provide injections to my patients while I am out of the office.
(False: Medical assistants may only administer injections under the direct supervision of a physician, physician assistant or nurse practitioner.
A.R.S. 32-1456. Direct supervision is defined in A.R.S. 32-1401 as being in the same room or office suite as the medical assistant.)
5. I can earn one credit hour of continuing medical education by reading scientific journals and books.
(True: A credit hour may be earned for activities that provide an understanding of current developments, skills, procedures, or treatments related to
the practice of allopathic medicine, including reading scientific journals and books. R4-16-101(B)(8).)
6. If the Board issues me a non-disciplinary advisory letter, I can file a written response with the Board within thirty days of receiving the advisory letter.
(True: An advisory letter cannot be appealed, but physicians do have the right to file a written response. The written response is considered to be
part of the public record and will be included with any public records requested on a physician.)
7. I am required to report to the Board any information that appears to show that a doctor of medicine is or may be medically incompetent, is or may be
guilty of unprofessional conduct, or is or may be physically unable safely to engage in the practice of medicine.
(True: A doctor of medicine is required to report to the Board any information that appears to show that a doctor of medicine is or may be medically
incompetent, is or may be guilty of unprofessional conduct, or is or may be physically unable safely to engage in the practice of medicine. A.R.S.
32-1451(A).)
8. I can charge a patient for medical records before I agree to send them to another physician.
(False: A health care provider may not charge for medical records provided to another health care provider for the purpose of providing continuing
care to the patient. A.R.S. 12-2295.)
9. If a patient asks for his medical records to be transferred to another provider, I am no longer responsible for retaining the records according to state
retention laws.
(False: The law does not provide an exception to the medical record retention requirements. A.R.S. 12-2297.)
10. The Arizona Medical Board can charge me $100 for failing to provide a current office and home address within 30 days of the date of the address
change.
(True: The Arizona Medical Board may assess the costs incurred by the Board in locating a licensee and in addition a penalty of not to exceed one
hundred dollars. A.R.S. 32-1435(B).)
T:\Licensing\New License Applications and forms\New License Application\Revised 2018\IMLCC Application Supplemental Form 03.18.2018
11. If I self report to the Board my substance abuse problem I may be eligible to participate confidentially in the Arizona Medical Board's treatment and
rehabilitation program.
(True: The Arizona Medical Board has a program for the treatment and rehabilitation of physicians who are impaired by alcohol or drug abuse.
Physicians meeting the program requirements may participate confidentially. A.R.S. 32-1452.)
12. I can prescribe to patients who fill out an on-line health questionnaire, even if I have never met them.
(False: It is unprofessional conduct to prescribe, dispense or furnish a prescription or prescription-only device to a person without first conducting a
physical examination or previously establishing a doctor-patient relationship. A.R.S. 32-1401(27)(ss).)
13. If I don't receive a reminder from the Arizona Medical Board to renew my license on time, I am not responsible for a late fee or non-renewal.
(False: It is your responsibility to ensure your license is renewed on time.)
14. If my patient refuses to notify her spouse that she is HIV positive, I can report the name of her spouse to the Arizona Department of Health Services.
(True: A.R.S. 32-1457 states that it is not an act of unprofessional conduct for a doctor to report to the department of health services the name of a
patient's spouse or sex partner or a person with whom the patient has shared hypodermic needles or syringes if the doctor knows that the patient
has contacted or tests positive for the human immunodeficiency virus and that the patient has not or will not notify these people and refer them to
testing.)
15. The Arizona Medical Board will only investigate a malpractice complaint if there was a settlement over one million dollars.
(False: On receipt of a malpractice report and a copy of a malpractice complaint as provided in section 12-570, the health profession regulatory
board shall initiate an investigation into the matter to determine if the licensee is in violation of the statutes or rules governing licensure.
A.R.S. 32-3203.)
After completion of the Medical Practice Act Training
and Questionnaire, please sign and date section #6 of
the Supplemental Forms.
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