03/2018
ORDER FORM: ARIZONA D.O. PHYSICIAN CREDENTIALING DATA FILE
The Arizona Board of Osteopathic Examiners produces an Excel file containing public information from the D.O. Physician database on a monthly
basis. This data file includes the following:
Office Address, City, State, Zip
In State or Out of State Practice
Board Action(s) Type and Date*
* See individual physician profiles on our website at www.azdo.gov for documents related to Board actions.
The Arizona D.O. Physician Credentialing Data File is provided as an attachment via email in Excel format.
Cost: $100.00 per data file transmission.
$25.00 for non-profit (501(c)(3)) organizations (must provide valid Federal documentation with order)
Government agencies – please forward your request to the Board office at questions@azdo.gov
To order, please complete the bottom portion of this form and mail completed form together with a check, money order or completed credit
card payment form (attached) to the Arizona Board of Osteopathic Examiners.
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(please print) Phone No.
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Name Fax No.
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City/S
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REQUIRED: Email address for data transfer:
(please
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Pursuant to A.R.S. § 39-121.03, please complete the following statement:
These records will be used for commercial non-commercial purposes.
If commercial purpose, specifically state for what purpose: _
The public records requested and described above are to be used solely for the purpose stated. They will not be used directly or indirectly for a
different purpose other than described. The information I have provided is true and correct.
By signing this form and submitting it to the Arizona Board of Osteopathic Examiners, I authorize this agency to debit the credit card identified on
the attached form or accept the enclosed check or money order for the purchase of an Arizona D.O. Physician Credentialing Data File at the cost of
$100.00 pe
r data file unless otherwise noted above.
Authorized Signature Date
Two ways to order and pay for the Arizona D.O. Physician Credentialing Data File
To pay by credit card
In addition to completing this form, please complete and submit the
"Credit Card Payment Form" and mail to the Board.
To pay by check or money order
Mail this form with your check or money order to the Board.
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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