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Arizona Medical Board (Arizona Medical Board)

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Arizona Medical Board
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Telephone:480-551-2700TollFree:877-255-2212
Website: www.azmd.gov
Attention Applicants
Thank you for your interest in obtaining a license to practice medicine in Arizona. We are excited to
have the opportunity to work with you and help guide you through the application process.
Our mission is to protect public safety through the judicious licensing, regulation and education of all
allopathic physicians. A license to practice medicine in Arizona is a privilege, not a right. Please do
not assume that licensure is a mere formality or that granting of a license is automatic. Please give
your application the time and attention needed to accurately answer all questions. It is the applicant's
responsibility to ensure that the information disclosed on the application is correct.
Once your completed application and fee are received by the Board, your application will be reviewed
to determine if all items needed to meet Arizona's Revised Statutes and Rules for licensure have been
submitted. A checklist is provided with this application packet for your convenience.
Pursuant to A.R.S. § 32-4302; If an applicant has any complaints, allegations or investigations pending
the Board will suspend the application process and may not issue or deny a license to the applicant until
the complaint, allegation or investigation is resolved.
We will make every effort to complete the application process as quickly as possible. If you have any
questions, please do not hesitate to call or email the Board's office. Our staff is happy to assist you in
any way we can.
Again, thank you for your interest in an Arizona medical license.
Revised 3/19/2020
Application Review Process:
Board staff will review your application and determine if all items needed to complete your application have
been submitted to the Board. If it is determined that your application has deficient items, Board staff will send
you a notice with a list of the items still needed to meet requirements. P lease allow 15 days for your
application to be reviewed by Board staff before calling and requesting a status update. Correspondence will
be sent to your email address provided on the application.
Once all information needed to meet the requirements for licensure have been submitted to the Board, your
application will undergo a final review by Board staff to ensure all require ments set forth in the Arizona
Revised Statutes have been met.
Please note: It is the applicant's responsibility to report to the Board any changes that may have occurred
during the application process. Failure to report any adverse actions to the Board during the licen sure
process may result in denial or revocation of your license.
To review the Arizona Revised Statutes to ensure that you meet the requirements for licensure,
please go to www.azmd.gov.
32-3208. Criminal charges; mandatory reporting requirements; civil penalty
A. A health professional who has been charged with a misdemeanor involving conduct that may affect
patient safety or a felony after receiving or renewing a license or certificate must notify the health
professional's regulatory board in writing within ten working days after the charge is filed.
B. An applicant for licensure or certification as a health professional who has been charged with a
misdemeanor involving conduct that may affect patient safety or a felony after submitting the
application must notify the regulatory board in writing within ten working days after the charge is filed.
C. On receipt of this information the regulatory board may conduct an investigation.
D. A health professional who does not comply with the notification requirements of this section commits an
act of unprofessional conduct. The health professional's regulatory board may impose a civil penalty of
not more than one thousand dollars in addition to other disciplinary action it takes.
E. The regulatory board may deny the application of an applicant who does not comply with the notification
requirements of this section.
F. On request a health profession regulatory board shall provide an applicant or health professional with a
list of misdemeanors that the applicant or health professional must report.
FOR YOUR INFORMATION
Revised 3/19/2020
Checklist for an MD Universal Recognition License Application
Please do not submit this form with your application. Keep it for your records.
APPLICATION FEE
Application Fee
The application fee is $500 payable by check or credit card. The application fee must
be submitted with the application and is non-refundable
License Fee
Once your license application is approved, you will be required to pay a prorated
licensure issuance fee up to $500. This fee is prorated based on your birth year and
month.
LICENSE APPLICATION
Completed Application
Provide a complete application, pages 1 - 8 Make sure page 5 is notarized. You must
complete all questions. If you fail to complete a question, your application will be
considered deficient and the processing of your application will be delayed.
FINGERPRINTS
Fingerprint Card & Fee
Applicants are required to undergo a criminal background check according to A.R.S. § 32-
4302(9). A fingerprint packet will be sent to the applicant's mailing address provided on
the application. The fingerprint card is specific and pre-printed for the Board; therefore,
the applicant must use the fingerprint card provided by the Board. Fingerprinting can be
done at a local police department, sheriff's office, or an entity that
provides fingerprinting
services. Please contact the entity that provides the fingerprint service and confirm
availability and payment requirements. The applicant is required to return the fingerprint
card along with a check, money order or credit card for $50.00 made out to "Arizona
Medical Board" together in the return envelope. The fingerprint technician is required to
fill out and date the identity verification form, place it with the fingerprint card and check
or money order, seal and sign the envelope flap before returning the fingerprint
card to the
applicant. If the applicant forgets to place the check or money order with the fingerprint
card, do not reopen the sealed envelope. The applicant can include the check or money
order in a separate envelope attached to the return fingerprint card envelope. Failure to
return the sealed envelope with the fingerprint card, identity verification form, check or
money order and the fingerprint technician's signature across the envelope flap will delay
the processing of your application. Do not send the fingerprint card prior to the
submission
of yourapplication.
EVIDENCE OF LEGAL STATUS
A notarized Copy of Your Birth
Certificate or Passport
Applicants must provide a notarized photocopy of a Birth Certificate or Passport.
A Notarized Certificate of Identification form is provided with the application packet
for your convenience.
Proof of Immigration status
A list of the documents that are required to be submitted to the Board is included with
the application.
Government Issued Photo ID (Copy)
A copy of a government issued photo ID is required if the proof of legal status does
not
include a photo. Example: driver license or state I.D.
Evidence of legal name change
Applicant must provide evidence of legal name change, if applicable. Example:
Marriage Certificate, court documents showing legal name change.
Revised 3/19/2020
QUESTIONNAIRE AFFIRMATIVE RESPONSES
Narrative and Supporting Documents
If you answer "yes" to a question on the questionnaire page, please provide the following:
A narrative/explanation of the circumstances that led to the issue disclosed.
Documents to support your narrative.
*If documents are not provided, this will delay the application process.
Please note: It is the applicant's responsibility to report to the Board any changes that
may have occurred during the application process. Failure to report any
adverse actions
to the Board during the licensure process may result in denial or revocation of your
license.
Proof
of established residency in Arizona
or Military Form 2058
Such as:
• A valid Arizona driver’s license
• A current Arizona motor vehicle registration
• Proof of filing Arizona income taxes in the most recent tax year
• Arizona voter registration
• Documentation of a mortgage for an Arizona residence
• A dated rental contract with proof of payment
• Proof of establishment of Arizona utilities
• Enrollment of children in Arizona schools of grades K-12
• Documentation demonstrating a change in permanent address on all pertinent
records
• Military Form 2058
Public Profile Addendum
Pursuant to A.R.S. § 32-1403.01(A) The board shall make available to the public a profile of
each licensee. The board shall make this information available through an internet website
and, if requested, in writing.
Information requested to be sent directly to the Board can be sent to the following:
DO NOT EMAIL APPLICATION(S)
Email: licensingreport@azmd.gov
Arizona Medical Board
1740 W. Adams. St. , Ste. 4000
Phoenix, AZ 85007-2664
Revised 3/19/2020
To be completed and signed by the applicant. All questions MUST be answered, even if only to indicate "None" or "N/A".
First Name:
Middle Name:
Last Name:
Other Names Used:
Social Security Number:
Date of Birth:
City of Birth:
State of Birth: Country of Birth:
Social Security Number, Date of Birth and Place of Birth are Confidential Information - Not for Public Disclosure
Address: City:
Phone: Mobile:
Same asPractice Address
Same as HomeAddress
Phone: Fax:
State: Zip:
*Practice address not required for licensure
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.
5.
Home
Address: City: State: Zip:
ARIZONA MEDICAL BOARD
MD UNIVERSAL RECOGNITION LICENSE APPLICATION
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
www.azmd.gov
Personal Information
Address Information
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.
4.
Practice Name:
Primary Email Address:
Mailing Address:
If no address is provided, all Board correspondence will be sent to your practice address. Please note - Your
fingerprint
packet will be sent to your mailing address.
6.
Address:
City: State: Zip:
2.
3.
Page 1 of 8
1.
Revised 3/19/2020
In addition to your primary e-mail address provided on page one of this application, please indicate if you would like to
designate/authorize an individual or prospective employer, beside yourself, to receive status updates on your application.
Please note: If a substantive review/investigation is required during the application process, the applicant will be required to
provide additional authorization, in writing, for the third party to receive status updates concerning the substantive review.
Name Phone# E-mail
Name Phone# E-mail
7
. Qualification for Universal Recognition License
Attach proof of residency or
Military Form 2058. A list of acceptable documentation establishing residency in Arizona
can be found on the application checklist.
I
have established residence in the state of Arizona.
I am a
person married to an active duty member of the armed forces of the United States who is stationed to a military
installation located
in the state of Arizona.
8
. Other State Medical License(s)
Please list all states in which you have applied for or have been granted a license to practice medicine, including license number,
date issued and current status of the license. If more than 10, attach a separate listing. If a license is pending or was not issued,
so state.
State Board: License No.: Date Issued: License Status:
First Name: Last Name:
Page 2 of8
Revised 3/19/2020
Full Name :
Signature:
9
. Citizenship Attestation
Proof
of Citizenship: Effective January 1, 2008, based on Federal and State laws, all applicants must provide evidence that the
applicant
is lawfully present in the United States, Pursuant to A.R.S. § 41-1080 and A.A.C. R4-16-201(C)(1) require
documentation
of citizenship or alien status for licensure. If the documentation does not demonstrate that the applicant is
a
United
States citizen, national, or a person described in specific categories, the applicant will not be eligible for licensure
in
Arizona
.
I am a U.S. Citizen or U.S.National.
If
this box is checked, please submit documentation as stated on the Statement of
Citizenship form (Also review
the application checklist).
I am NOT a U.S. Citizen or U.S. National.
If
this box is checked, please submit documentation as stated on the
Statement of
Citizenship form (Also review
the application checklist).
10
. Questionnaire
1. Are you currently under investigation by any medical board?
(Pursuant to A.R.S. § 32-4302(A)(7) If an applicant has any complaints, allegations or investigations pending the Board
will suspend the application process and may not issue or deny a license to the applicant until the complaint,
allegation or investigation is resolved.)
2. Have you ever had a medical license in any state or country disciplined resulting in a revocation,
suspension, limitation, restriction, probation, voluntary surrender, cancellation during an
investigation, or entered into a consent agreement orstipulation?
Yes No
Yes No
Page 3 of8
Date:
11
. Training Unit Attestation
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.
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 this application and available on the Board's website.
3. Have you ever been convicted of a crime? If yes, provide court records of all convictions including
all applicable records of set asides or expungements. (Do not include juvenile convictions.)
Yes No
Initials
NOTE: In the event that the response to any of the questions is "Yes", you must file an explanation and submit photocopies of any
corresponding documents. Failure to properly answer these questions can result in Board disciplinary action, including revocation or
denial of license.
Revised 3/19/2020
12.
Public Profile Addendum
Pursuant to A.R.S. § 32-1403.01(A) The board shall make available to the public a profile of each licensee. The board shall
make this information available through an internet website and, if requested, in writing.
Medical School Name:
Medical School Location: Graduation Date:
Institution: City: State:
Dates of Attendance: Beginning: Ending:
Type of Program:
Specialty:
Page 4 of8
Post Graduate Training Information
First Name: Last Name:
Area of Interest
Indicate your area of interest/specialty:
Institution: City: State:
Dates of Attendance: Beginning: Ending:
Type of Program:
Specialty:
Institution: City: State:
Dates of Attendance: Beginning: Ending:
Type of Program:
Specialty:
Revised 3/19/2020
Arizona Medical Board Universal Recognition Application Attestation
I attest that all of the information contained in the application and accompanying evidence or other credentials submitted are
true. I attest the credentials submitted with the application were procured without fraud or misrepresentation or any mistake of
which I am aware, and that I am the lawful holder of the credentials. I authorize the release of any information from any source
requested by the Board necessary for initial and continued licensure in thisstate.
Failure to report any adverse actions to the Board during the licensure process may result in denial or revocation of
your license.
Signature of Applicant: Date:
Notarization
Subscribed and sworn in front ofme by , personally appearing on this date .
Applicant Name
Notary Public's Signature
(PersonalizedSeal)
First Name: Last Name:
Page 5 of8
Revised 3/19/2020
CERTIFICATION OF IDENTIFICATION
Certification by Notary Public is Required
Applicant Full LegalName:
Last First Middle
Notary - Please complete the section below and attach a photocopy of the Birth
Certificate or Passport.
State of Countyof
I certify that on the date set forth below, the individual named above, did appear personally before me
and presented one of the following forms of identification as proof of his/her identity (Birth Certificate
or Passport). I further certify that I did identify this applicant by comparing his/her physical appearance
with the photograph on a Government issued photo identification presented by the applicant.
The statements on this document are subscribed and sworn to before me by the applicant on this
(Day) , of (Month) , (Year) .
Notary PublicSignature:
Commission Expiration Date* (Month) /(Day) /(Year)
*The notary's commission expiration date must be current and legible. If no expiration date, such as
'lifetime', an explanation must be provided.
Applicant'sSignature:
Notary Stamp Here
Please complete and mail or email the notarized Certificate of Identification form and a photocopy of the
Birth Certificate or Passport presented to the Notary to:
Arizona Medical Board
1740 W. Adams St. Ste.4000
Phoenix, AZ 85007-2664
LicensingReport@azmd.gov
Page 6 of8
Revised 3/19/2020
M.D. Universal Recognition 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)
TYPE OF APPLICATION (Check one)
INITIAL APPLICATION RENEWAL
TYPE OF LICENSE/CERTIFICATION (Check one)
MD Initial or Universal Recognition
Application Education Teaching Permit
Post Graduate TrainingPermit
Teaching License
Pro bono registration
Locum Tenens
Are you a citizen or national of the United States?
Yes No
If Yes, indicate place of birth:
City of Birth: State (or equivalent):
Country or Territory:
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.
Name of document:
2) Go to Section IV.
If you answered No, you must complete Section III and IV.
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 certified 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.
Name of document provided:
Qualified Alien Status (8 U.S.C.§§ 1621(a)(1),-1641(b) and (c))
1 of 2
SECTION II – CITIZENSHIP OR NATIONAL STATUS DECLARATION
ARIZONA STATEMENT OF CITIZENSHIP
OR ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Commercial License
Arizona Medical Board
SECTION III
–
ALIEN STAT
U
S DE
C
LARATION
Page 7 of8
Revised 3/19/2020
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.
Nonimmigrant 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).
Alien 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 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:
2 of 2
Page 8 of8
Revised 3/19/2020
Evidence of U.S. Citizenship, U.S. National Status, or Alien Status
License Application Types: MD Universal Recognition 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.
Revised 3/19/2020
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\MD Initial Application\Revised 2018\06.19.2018
Revised
10/20/2015
Revised
3/19/2020
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.
Revised 3/19/2020
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).)
Revised 3/19/2020
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.)
Revised 3/19/2020
Mailto: 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 license application and all necessary documents. Return the application and
payment form (credit card form, check or money order) to the address listed below
Date:
Zip:State:City:
Mailing Address of Cardholder:
(If different from billing address)
OfficePhone:
Zip:State:City:
Billing Address of Cardholder:
(Required)
(No dashes between numbers)
Name as Shown on PaymentCard:
ExpirationDate:
CardNumber:
Visa Mastercard Amex
Type of Card:
LastNameFirstName
PAYMENT CARD AUTHORIZATION
Note: At the time the application is approved an additional prorated fee will be required up to $500. This is in addition to your $500
application fee and will cover your license through the next renewal period.
CardholderSignature:
(Required)
MD UNIVERSAL RECOGNITION APPLICATION PROCESSING FEE $500
MD FINGERPRINT FEE $50
TOTAL DUE: $550
Revised 3/19/2020
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Completed 20 July 2020

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