T:\Licensing\New License Applications and forms\New License Application\MD Initial Application\MD Application\Revised 2018\03.19.2018
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 judgement 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
4. 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?
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 program or by any health care provider?
5. Have you had hospital privileges revoked, denied, suspended, or restricted?
(do not report if your hospital privileges were suspended due to failure to compete hospital record
and reinstated after no more thatn 90 days)
6. 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
7. 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?
8. Have you been found guilty or entered into a plea of no contest to a felony, a
misdemeanor involving moral turpitude, or an alcohol or drug-related offense in any state?
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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.
9. Have you failed the special purpose licensing examination (SPEX)?
First Name: Last Name:
10. Have you engaged in the practice of medicine while on inactive status?