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Attention Applicants Arizona Medical Board Thank you for (Arizona Medical Board)

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Revised 7/30/2019
Arizona Medical Board
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Telephone: 480- 551-2700 Toll Free: 877-255-2212
Website: www.azmd.gov
Attention Applicants
Thank you for your interest in obtaining a locum tenens registration in Arizona. We are
excited to have the opportunity to work with you and help guide you through the application
process.
Please be aware that this is not an expedited license. A locum tenens registration can take
just as long to process as a full unrestricted license due to Arizona Revised Statutes and rule
requirements. A Arizona Locum Tenens Registration is only valid for one hundred and
eighty (180) consecutive days. The registration will be issued only once in a three year
period.
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. Please understand that some of the documentation required
for licensure must come from the primary source (third party). This can add time to the
licensing process. It is the applicant's responsibility to request the documentation from the
primary source to be sent directly to the Board. A checklist is provided with this application
packet for your convenience.
Some applications evidencing a history of disciplinary action require in-depth investigation
and may require additional time and your cooperation. It may become necessary for an
applicant to come to the Board's office in Phoenix for an interview as part of the application
process. Additionally, if an investigation is required, your application may go before the full
Board for consideration of your application.
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 obtaining a locum tenens registration in Arizona.
Revised 7/30/2019
FOR YOUR INFORMATION
Documents submitted prior to your license application:
To ensure your application is processed in a timely manner, you may request your documents to be sent directly
from the entity to the Board prior to the submission of your application. Documents received prior to the
submission of your application will be kept on file with the Board for 365 days.
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. Please 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. If all documents are not received within 90 days from the date of the notice
letter detailing documentation required, your application will be withdrawn and the application fee forfeited.
Once all information needed to meet the requirements for a locum tenens registration have been submitted to the
Board, your application will undergo a final review by Board staff to ensure all requirements set forth in the
Arizona Revised Statutes and Rules 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 licensure process may result
in denial or revocation of your license.
To review the Arizona Revised Statutes and Rules 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.
Revised 7/30/2019
Checklist for a Locum Tenens Registration
MEDICAL EMPLOYMENT
APPLICATION AND REGISTRATION FEE
Application and Registration Fee
The application and registration fee is $350 payable by check or credit card. The
application and registration fee must be submitted with the application and is non-
refundable
Please do not submit this form with your application. Keep it for your records.
Page 1 of 3
EVIDENCE OF LEGAL STATUS
A Copy of Your Birth Certificate or
Passport
Applicants must provide a photocopy of a Birth Certificate or Passport.
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.
FINGERPRINTS
Fingerprint Card
Applicants are required to undergo a criminal background check according to
A.R.S. § 32-1422(12). 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 your application.
Completed Application
Provide a complete application, pages 1 - 9. You must complete all questions. Make sure
page 7
is notarized. If you fail to complete a question, your application will be considered
deficient and the processing of your application will be delayed.
LICENSE APPLICATION
Medical Employment Verifications
You must request verification(s) from the following;
·
Verification(s) of all medical employment, to include all medical professional activities
for the five years preceding the date of the application, to be sent directly to the Board.
Please Note: Due to the change in A.R.S. § 32-1422 (11) (a), the Arizona Medical Board no
longer requires verification of hospital privileges. Hospitals should only be listed below if
the hospital is the employer.
Revised 7/30/2019
POST GRADUATE TRAINING
Post Graduate Training Certification
The post graduate training form is included with the application. This form must be filled
out and submitted directly to the Board from the post graduate training program. It is
the applicant's responsibility to provide this form to the training program.
The Board must receive verification from your training program for the following:
U.S. or Canadian Graduates:
12 months of ACGME and/or RCPSC approved post graduate training
Foreign Graduates:
36 months of ACGME and/or RCPSC approved post graduate training
Please note: Only verified postgraduate training from the primary source will be added
to your website profile upon approval of your license.
Page 2 of 3
VERIFICATION OF OTHER STATE LICENSE(S)
State/Province Licensure Verification
License verification is required to be sent directly to the Board from each state or province
in which you hold or have held a license. Verification(s) of training permits or registrations
are not required. If you obtain a license during the licensure process, you must request the
verification to be sent directly to the Board. *The Board accepts verifications from Veridoc.
MEDICAL SCHOOL
Medical College Certification
One of the following must be submitted directly from your medical school to the Board:
- An official copy of your medical school transcript
- A copy of your Diploma
- A letter with an official letterhead that confirms successful completion
Foreign graduates only:
ECFMG Certification, 5th Pathway or 36
months Clinical Instructor Certification
ECFMG certification must be sent directly to the Board, available online at www.ecfmg.org.
A clinical instructor must complete 36 months as a full-time employed/compensated
assistant professor or higher.
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. Example: Court documents, Board Orders, etc.
*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.
Sponsoring Physician Form
Sponsoring Physician Form
This form is to be completed and submitted to the Board by the Arizona sponsoring
physician requesting a locum tenens to cover or assist in his/her practice. The form is
provided with the application packet This form cannot be submitted by the applicant, it
must come directly from the sponsoring physician.
Revised 7/30/2019
Page 3 of 3
Arizona Revised Statutes for a Locum Tenens Registration
A.R.S. § 32͈1429 ͈ Locum tenens registration
A. The board may issue a registration to allow a doctor of medicine who is
not a licensee to provide locum tenens medical services to
substitute for or temporarily assist a doctor of medicine who holds an active license pursuant to this chapter or a doctor of osteopathy
who holds an active license pursuant to chapter 17 of this title under the following conditions:
1. The applicant holds an active license to practice medicine issued by a state, district, territory or possession of the United States.
2. The applicant provides on forms and in a manner prescribed by the board proof that the applicant meets the applicable requirements
of section 32͈1422, 32͈1423 or 32͈1424.
3. The license of the applicant from the jurisdiction in which the applicant regularly practices medicine is current and unrestricted and
has not been revoked or suspended for any reason and there are no unresolved complaints or formal charges filed against the applicant
with any licensing board.
4. The doctor of medicine or doctor of osteopathy for whom the applicant for registration under this section is substituting or assisting
provides to the board a written request for locum tenens registration of the applicant.
5. The applicant pays the fee prescribed under section 32͈1436.
B. Locum tenens registration granted pursuant to this section is valid for a period of one hundred eighty consecutive days. A doctor of
medicine is eligible to apply for and be granted locum tenens registration once every three years.
Arizona Administrative Code (Rules) for a Locum Tenens Registration
A.A.C. R4͈16͈203. Application for Locum Tenens Registration
A. An applicant for a locum tenens registration to practice medicine for a maximum of 180 consecutive days in Arizona shall submit an
application available on request from the Board and on the Board’ web site that provides the information required under by R4͈16͈
201(B).
B. In addition to the application form required under subsection (A), an applicant for a
locum tenens registration to practice medicine
shall have the following submitted directly to the Board, electronically or in hard copy, y the primary source, ECFMG, Veridoc, or FCVS:
1. Official transcript or other authentication of graduation from a school of medicine;
2. Verification of completion of postgraduate training;
3. A statement completed by the sponsoring Arizona͈licensed physician giving the reason for the request for issuance of the registration;
4. Verification of ECFMG certificate if the applicant graduated from an unapproved school of medicine; and
5. Verification of licensure from every state in which the applicant has ever held a medical license.
C. In addition to the application form required under subsection (A), an applicant for a locum tenens registration to practice medicine
shall submit the following:
1. Documentation listed under A.R.S. § 41͈1080(A) showing that the applicant’ presence in the U.S. is authorized under federal law;
2. A full set of fingerprints and the charge specified in R4͈16͈205;
3. A copy of a government͈issued photo identification; and
4. The fee specified under R4͈16͈205.
Information requested to be sent directly to the Board can be sent to the following:FCVS PACKETSInformation requested to be sent directly to the Board can be sent to the following:
Arizona Medical Board
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
www.azmd.gov
Email: licensingreport@azmd.gov
Revised 7/30/2019
Social Security Number, Date of Birth and Place of Birth are Confidential Information - Not for Public Disclosure
ARIZONA MEDICAL BOARD
MD LOCUM TENENS REGISTRATION
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
www.azmd.gov Email: licensingreport@azmd.gov
Page 1 of 9
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.
Address Information
Phone: Fax:
Zip:State:City:Address:
Practice/Training Name:
Zip:State:City:Mailing Address:
5.
7.
*Practice address not required for licensure
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.
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.
City:
Phone: Mobile:
Zip:State:Home Address:
5.
Primary Email Address:
6.
Same as Practice Address Same as Home Address
Date of Birth:
Other Names Used:
Last Name:
Middle Name:
First Name:
Social Security Number:
1.
2. 3.
City of Birth:
State of Birth:
or
Country of Birth:
4.
Please be aware that this is not an expedited license. An Arizona Locum Tenens Registration is valid for one hundred eighty
(180) consecutive days. The registration will be issued only once in a three year period. The physician issued the locum
tenens registration is not eligible for a DEA number in Arizona. A locum tenens registration allows the physician to practice
medicine only at the location and for the Arizona licensee as approved by the Board.
To be completed and signed by the applicant. All questions MUST be answered, even if only to indicate "None" or "N/A".
Personal Information
Revised 7/30/2019
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.
My license from the jurisdiction in which I regularly practice medicine is current and unrestricted and has not been
revoked or suspended for any reason and there are no unresolved complaints or formal charges filed against me with any
licensing board.
First Name: Last Name:
Page 2 of 9
E-mailPhone#Name
E-mailPhone#Name
Other State Medical License(s)
Please list all states, provinces or U.S. territories in which you have applied for or have been granted a license or registration 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. Please do not list registrations or post graduate training license(s). If
none, please indicate "Not Applicable".
State Board: License No.: Date Issued: License Status:
8. 9.
Date:
Full Name (print):
Signature:
No Unresolved Complaints or Formal Charges
8.
Revised 7/30/2019
Medical Education
Graduation Date:
10.
Page 3 of 9
I am able to read, write, speak, understand and
be understood in the English language.
If you graduated from a medical school located outside the United States of America or Canada, please list below:
ECFMG No.:
Certificate Date:
Medical School Name:
Medical School Location:
Institution:
List chronologically, all internship, residency and fellowship training in the U.S. or Canada (completed or not), or assistant
professorship (or higher, if needed to meet requirements) at any program attended, showing institution, address, type of
program, specialty and dates. Attach a separate listing, if needed.
Post Graduate Training
a.
City: State:
Type of Program:
To:From:
Dates of Attendance:
Specialty:
11.
Specialty:
City:Institution:
b.
State:
Type of Program:
To:From:
Dates of Attendance:
City:Institution:
c.
State:
Type of Program:
To:From:
Dates of Attendance:
Specialty:
Type of Program:
Institution:
d.
City: State:
To:From:
Dates of Attendance:
Specialty:
Institution:
Type of Program:
e.
City: State:
To:From:
Dates of Attendance:
Specialty:
First Name: Last Name:
Revised 7/30/2019
Page 4 of 9
Examinations
United States Licensing Exam (USMLE)
National Board of Medical Boards Licensing
Examination (NBME)
State Written Exam
Federation of State Medical Boards Licensing
Examination (FLEX)
Licentiate of the Medical Council of Canada (LMCC) Special Purpose Examination (SPEX)
Please indicate all exams taken.
12.
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).
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). This must be completed.
Area of Interest Practicing? ABMS Certified?
Expiration Date
(Or indicate if lifetime certificate)
NoYes NoYes
NoYes NoYes
NoYes NoYes
13.
14.
Training Unit Attestation
15.
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):
Revised 10/20/15
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.
Signature:
Revised 7/30/2019
1. Have you received treatment within the last five years for use of alcohol or a controlled substance,
prescription-only drug, or dangerous drug or narcotic or a physical, mental, emotional, or nervous
disorder or condition that currently affects your ability to exercise the judgment and skills of a
medical professional? If so, provide the following:
A.) A detailed description of the use, disorder, or condition; and
B.) An explanation of whether the use, disorder, or condition is reduced or ameliorated because you receive ongoing treatment and if so,
the name and contact information for all current treatment providers and for all monitoring or support programs in which you are
currently participating.
C.) A copy of any public or confidential agreement or order relating to the use, disorder, or condition, issued by a licensing agency or health
care institution within the last five years, if applicable.
The purpose of the confidential question is to allow the Board to determine the applicant's current fitness to practice medicine. The mere fact of treatment, monitoring or
participation in a support group is not, in itself, a basis of which admission is denied; the Board routinely licenses individuals who demonstrate personal responsibility and
maturity in dealing with fitness issues. The Board encourages those applicants who may benefit from assistance to seek it. The Board may limit or deny licensure to applicants
whose ability to function is impaired in a manner relevant to the practice of medicine at the time the licensing decision is made or to applicants who demonstrate a lack of
candor by their responses. This is consistent with the public purpose that underlies the licensing responsibilities assigned to the Arizona Medical Board and to the applicants
seeking licensure.
Questionnaire
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
8. Have you been named as a defendant in a malpractice matter currently pending or that resulted in a
settlement or judgment against you? If so, provide a statement specifying the nature of the occurrence
resulting in the medical malpractice action.
NoYes
6. Have you ever had a medical license disciplined resulting in a revocation, suspension, limitation,
restriction, probation, voluntary surrender, cancellation during an investigation, or entered into a
consent agreement or stipulation?
NoYes
NoYes
2. Have you had any disciplinary or rehabilitative action taken against you by another licensing board,
including other health professions?
1. Have you had an application for medical licensure denied or rejected by another state or province
licensing board?
3. Have you had any disciplinary actions, restrictions or limitations taken against you while participating
in any type of training program or by any health care provider?
4. Have you been found in violation of a statute, rule, or regulation of any domestic or foreign
governmental agency?
NoYes
5. Are you currently under investigation by any medical board or peer review body?
7. Have you had hospital privileges revoked, denied, suspended, or restricted?
9. Have you been subjected to any regulatory disciplinary action, including censure, practice restriction,
suspension, sanction, or removal from practice, imposed by an agency of the federal or state
government?
10. Have you had the authority to prescribe, dispense or administer medications limited, restricted,
modified, denied, surrendered, or revoked by a federal or state agency as a result of disciplinary or
other adverse action?
11. Have you been found guilty or entered into a plea of no contest to a felony, or a misdemeanor
involving moral turpitude in any state?
NoYes
Page 5 of 9
Confidential Question
Last Name:First Name:
16.
17.
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.
Moral Turpitude includes but is not limited to: Armed Robbery, Assault with a Deadly Weapon, Attempted Insurance Fraud, Embezzlement,
Fabricating and Presenting False Public Claims, False Reporting to Law Enforcement Agency, Falsification of Records of the Court, Forgery,
Fraud, Hit & Run, Illegal Sale and Trafficking in Controlled Substances, Indecent Exposure, Kidnapping, Larceny, Mann Act (Federal
Commercialization of Women Statute), Misleading Sale of Securities in Connection with transfer of Real Property, Perjury, Possession of
Heroin for Sale/Unlawful Sale or Dispensing Narcotic Drugs, Rape, Shoplifting, Theft and Soliciting Prostitution.
Revised 7/30/2019
Medical Employment Verifications
18.
Name:
a.
From: To:
State:
City:
Address:
Position Held:
False
True
1. I have had no medical employment for the past five (5) years
False
True
2. I am currently in post graduate training.
(If true, do not list your post graduate training below).
Page 6 of 9
From:
Zip:
To:
State:
City:
Address:
Position Held:
Name:
From: To:
State:
City:
Address:
Position Held:
Name:
From:
State:
City:
Address:
Position Held:
Name:
From:
State:
City:
Address:
Position Held:
Name:
b.
c.
d.
e.
First Name: Last Name:
Please answer all questions and list all medical employment, to include all medical professional activities for the five years
preceding the date of the application. List all physician placement groups related to employment, emergency medical
groups, radiology groups, etc. Do not include postgraduate training.
Please Note: Due to the change in A.R.S. § 32-1422 (11) (a), the Arizona Medical Board no longer requires
verification of hospital privileges. Hospitals should only be listed below if the hospital is the employer.
Zip:
Zip:
Zip:
Zip:
Revised 7/30/2019
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 this state.
Signature of Applicant: Date:
Notarization
Subscribed and sworn in front of me by___________________________, personally appearing on this date______________________.
________________________________
Notary Public's Signature
(Personalized Seal)
Page 7 of 9
Attestation
19.
Last Name:First Name:
Applicant Name
Revised 7/30/2019
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
OVER
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:
Page 8 of 9
20.
TYPE OF LICENSE/CERTIFICATION (Check one)
Revised 7/30/2019
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:
Page 9 of 9
Revised 7/30/2019
Evidence of U.S. Citizenship, U.S. National Status, or Alien Status
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 copy of a birth certificate
Or
2. A 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 7/30/2019
SPONSORING PHYSICIAN FORM
TO BE COMPLETED AND SUBMITTED TO THE BOARD BY THE ARIZONA LICENSED
PHYSICIAN WHO THE LOCUM TENENS WILL BE SUBSTITUTING FOR OR ASSISTING
NAME OF LOCUM TENENS APPLICANT
Phone: Fax:
Zip:State:City:Address:
Phone: Fax:
Zip:State:City:Address:
(Attach separate listing if needed)
1. Location(s) where Locum Tenen will assist/substitute for sponsoring Physician:
2. Reason(s) for request of Locum Tenens Registration:
3. Exact date for which Locum Tenens is requested:
Date FROM
Date TO
(Arizona Licensed Physician Print Name)
Arizona License Number
(Arizona Licensed Physician Signature)
Date
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.
Revised 7/30/2019
ons and forms\New License Application\MD Locum Tenens\Revised 2018\06.05.2018
Revised
10/20/2015
Revised 7/30/2019
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.
click to sign
signature
click to edit
Revised 7/30/2019
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 7/30/2019
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.)
Please fill out the Training Unit Attestation on page 4 of this application. It is not necessary to return the training unit with
your application.
Revised 7/30/2019
Date:Signature:
Last Name:First Name:
AUTHORIZATION: The Arizona Medical Board requires all applicants for licensure to obtain verification of all postgraduate
training programs attended. This form must be completed by the Program Director. This is authorization to release any
information in your files of record, favorable or otherwise, DIRECTLY to the Arizona Medical Board. Authorization may be sent
via mail to 1740 W. Adams St. Ste. 4000, Phoenix, AZ 85007-2664 or fax with cover letter to: 480-551-2704 or via email to
licensingreport@azmd.gov.
ARIZONA MEDICAL BOARD
POSTGRADUATE TRAINING VERIFICATION FORM
Important - Program Participation: Report incomplete postgraduate years (PGY) separately from those that were successfully completed. If
the postgraduate year is currently in progress, report the expected completion date in the "To" field. Report internships, residencies and
fellowships separately.
PG Year:
Department/Specialty:
Internship
Residency
Fellowship
To:From:
Successfully Completed?
Yes No In Progress
(mm/dd/yy)
Middle Name:
Applicant: Do not fill in below this line.
In ProgressNoYes
Successfully Completed?
To:From:
Fellowship
Residency
Internship
Department/Specialty:
PG Year:
In ProgressNoYes
Successfully Completed?
To:From:
Fellowship
Residency
Internship
Department/Specialty:
PG Year:
Fax:
Address:
Name:
Institution Name:
Affix Training Program Seal Here
(mm/dd/yy)
(mm/dd/yy)
Date:
(mm/dd/yy)
Phone:
Address:
(If yes, please attach an
explanation)
1. This program was approved for postgraduate training during that period by the Accreditation Council for Graduate Medical
Examination Education (ACGME), or the Royal College of Physicians and Surgeons of Canada:
NoYes
2. Did this individual ever take a leave of absence or break from training or request a transfer?
3. Was this individual disciplined and/or placed under investigation or probation?
Yes No
Yes No
(If yes, please attach an
explanation)
Signature:
Zip:State:
City:
Title:
Revised 7/30/2019
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 license application and all necessary documents. Return the application and
payment form (credit card form, check or money order) to the address listed below.
(Required)
Cardholder Signature:
Date:
Zip:State:City:
(If different from billing address)
Mailing Address of Cardholder:
(Required)
Office Phone:
Zip:State:City:Billing Address of Cardholder:
Name as Shown on Payment Card:
(No dashes between numbers)
Expiration Date:
Card Number:
AmexMastercardVisa
Type of Card:
MD LOCUM TENENS REGISTRATION APPLICATION PROCESSING FEE $350
MD FINGERPRINT FEE $50
TOTAL DUE: $400
Last NameFirst Name
PAYMENT CARD AUTHORIZATION
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