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DISPOSAL OF INVENTORY OF DRUGS AND DEVICES Ph (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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01/2018
DISPOSAL OF INVENTORY OF DRUGS AND DEVICES
A.R.S. §
32-1871(F)
IF PHYSICIAN FAILS TO RENEW OR CEASES TO
DISPENSE,
PHYSICIAN MUST PROVIDE THIS INFORMATION TO THE BOARD WITHIN THIRTY (30)
DAYS.
Name
of
Licensed
Physician:
License
No.:
_
Mailing
address:
City/State/Zip:
_
Phone
No.
(Day):
List each location(s) at which Doctor was formerly registered to
dispense.
If your inventory was transferred to another licensed health care provider or left with a licensed health
care
institution by which you were employed, it is not necessary to attach the inventory
itself.
Clinic Name & Address
Drugs and Devices
Manner of Disposal
Date of
Disposal
I, the licensed physician named above, do hereby attest that the inventory of drugs and devices from which I formerly
dispensed was disposed of in the above manner:
_
Signature Date
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
__________________________________________________________________________________________________________________________________________________________
click to sign
signature
click to edit
01/2018
ARIZONA BOARD OF OSTEOPATHIC EXAMINERS IN MEDICINE AND SURGERY
9535 EAST DOUBLETREE RANCH ROAD SCOTTSDALE, ARIZONA 85258
PH (480) 657-7703 | FX (480) 657-7715 www.azdo.gov | questions@azdo.gov
SAMPLE
DISPOSAL OF INVENTORY OF DRUGS AND DEVICES
A.R.S. §
32-1871(F)
IF PHYSICIAN FAILS TO RENEW OR CEASES TO
DISPENSE,
PHYSICIAN MUST PROVIDE THIS INFORMATION TO THE BOARD WITHIN THIRTY (30)
DAYS.
Name of Licensed Physician:
John Q. Smith, D.O.
License No.: 0024
Mailing address: 45678 Main Street, Suite 100 _
City/State/Zip:
This Town, AZ
85000
Phone No. (Day): 480-555-5678
List each location(s) at which Doctor was formerly registered to
dispense.
If your inventory was transferred to another licensed health care provider or left with a licensed health
care
institution by which you were employed, it is not necessary to attach the inventory
itself.
Clinic Name & Address Drugs and Devices Manner of Disposal
Date
of
Disposal
Sunny Urgent Care
(all locations) N/A
Left with Sunny Care, a licensed
health care institution 12/27/08
My Office
1234 Main St
Mytown AZ
See attached Disposed as required by DEA 1/4/09
Desert Medical Spa
123 Dune Blvd
HighHills, AZ
3 vials of Botox Returned to vendor for credit 11/17/08
My Old Office
567 Main St
Mytown AZ
N/A Sold inventory with practice to
Lee Newdoc, D.O.
7/3/2008
Sunny Urgent Care
(all locations) N/A
Left with Sunny Care, a licensed
health care institution 12/27/08
I, the licensed physician named above, do hereby attest that the inventory of drugs and devices from which I formerly
dispensed was disposed of in the above manner:
John Q Smith 01/08/2018
_
Signature Date
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Completed 20 July 2020

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