Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 West Adams Street, Suite 2000
Phoenix, AZ 85007-2607
Phone: (602) 771-7800
Homepage: h
ttp://www.azbn.gov
LICENSE/CERTIFICATE HOLDER’S
REQUEST FOR COPY OF COMPLAINT
,
request a copy of the complaint filed against my
I
.
I understand the Board reserves the right to redact information regarding the identity of the
complainant’s or witness information if there is potential risk to the complainant or witnesses
should the identities be disclosed.
I understand that a copy of the complaint is provided to me in confidence to assist in my
responding to the complaint and may not to be disclosed or provided to any other person except
to an attorney or an attorney’s employee who I have consulted or retained for legal
representation in connection with the Board of Nursing’s investigation.
I understand that pursuant to A.R.S. § 32-1664 (M) and (N), disclosure of the information
contained in the complaint documents received from the Board constitute a violation of the
Nurse Practice Act and may result in disciplinary action.
LICENSE/CERTIFICATE HOLDER’S SIGNATURE
DATE
CONSULTANT INITIAL: (Case No.: ) ( )
DATE:
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