Fillable LICENSE VERIFICATION REQUEST FORM (Arizona Medical Board)

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LICENSE VERIFICATION REQUEST FORM (Arizona Medical Board)

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The LICENSE VERIFICATION REQUEST FORM (Arizona Medical Board) form is 2 pages long and contains:

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  • 15 check-boxes
  • 34 other fields

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File type: PDF

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Please Note: All full MD license verifications that are to be sent only to another state medical board will be processed
by Veridoc. Please click on the following link for full MD license verifications to be sent to another state medical
board: www.veridoc.org
The Board will continue to provide license verifications for all other verification requests including full MD verifications
not being sent to another state medical board, Post Graduate Training Permits, PA Licenses, Locum Tenens, Pro
Bono and Teaching Certificates. Please fill out and submit the following form for all other license verification requests.
Licensee Name: Licensee Date of Birth (if known): Licensee No. (if known):
Requestor's Name (if different than licensee):
Requestor's Address: City: State: Zip:
Phone Number (if there are questions pertaining to your request):
(Specify delivery method):
State:
Delivery Method (Select One):
Mail (Please fill out mailing address)
Address: City: Zip:
Fax (Please contact the Board/Organization prior to selecting this option to ensure they accept faxed verifications)
Fax Number:
Other:
Credit Card (Please fill out credit card payment form and return with this Verification Request Form)
Payment Method (Select One):
Check (Enclose with this form. Make payable to Arizona Medical Board)
Name of the Board/Organization where the verification will be sent:
Please mail the completed license verification
request form to:
Arizona Medical Board
Attn: Verifications
1740 W. Adams St, Suite 4000
Phoenix, AZ 85007
Note: There is a $10 fee per license verification. If payment does not accompany this form, the verification request will not be
processed and will be returned to the requestor. The Board is not responsible for verifications that have been processed and sent, but
not received by the intended recipient. There is a $10 fee for verifications that must be re-sent. A method of delivery which provides
tracking service, such as FedEx, is recommended to ensure receipt.
Type of Arizona License to be Verified:
M.D. (Only if verification is not being sent to another state board.)
M.D. Resident/Post-Graduate Training
M.D. Locum Tenens
Arizona Medical Board
Arizona Regulatory Board of Physician Assistants
LICENSE VERIFICATION REQUEST FORM
Attention To:
M.D. Pro Bono
M.D. Teaching License
M.D Temporary License
P.A. License
Please complete and return this form with your verification request if paying by credit card. Or return the invoice and check
or money order to the address listed below. PLEASE NOTE: The Arizona Medical Board will only accept credit card payment
via mail (US, FedEx, UPS, or any other mail carrier). Any credit card information received via any other method will not be
processed and will be destroyed.
Date:
Cardholder Signature:
(If different from billing address)
Zip:State:City:Mailing Address of Cardholder:
Phone:
(Required)
Name as Shown on Payment Card:
(No dashes between numbers)
Card Number:
AmexMastercardVisa
Type of Card:
License Number:
Payment for:
PAYMENT CARD AUTHORIZATION
LICENSE VERIFICATION $10.00
Zip:State:City:Billing Address of Cardholder:
Mail to:
Arizona Medical Board
Attn: Verifications
1740 W. Adams St, Suite 4000
Phoenix, AZ 85007
Expiration Date:
(Required)
For receipt, please include an e-mail address for submission.
E-mail:
03/19/2018
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LICENSE VERIFICATION REQUEST FORM (Arizona Medical Board)

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Completed 20 July 2020

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