Fillable LOCUM TENENS REGISTRATION APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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LOCUM TENENS REGISTRATION APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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  • 21 check-boxes
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01/2018 Page 1
LOCUM TENENS REGISTRATION APPLICATION
Fee: $300.00
THIS AREA FOR OFFICIAL USE ONLY
A person who holds a Locum Tenens Registration may assist or substitute for an Arizona Sponsoring Physician.
They may not practice osteopathic medicine in this state apart from the facilities of the Sponsoring Physician.
This application is in accordance with A.R.S. § 32-1823. The filing of this application does not grant any special privilege to open an office or to
conduct any method of treating the sick or afflicted in the State of Arizona nor does it imply or guarantee that a regular license to practice
osteopathic medicine and surgery in Arizona will be granted upon application.
If approved, the Locum Tenens registration certificate will be mailed to the sponsoring physician.
In accordance with A.R.S. § 41-1030 The Board is required to notify you of the following:
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by
statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing
requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or
condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney
fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this
section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal
pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
SECTION 1: APPLICANT IDENTIFICATION AND CONTACT INFORMATION – REQUIRED
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
______________________________________________________________________________________________________________________________________
Attach a photograph
for identification purposes
Approximately
2” x 2”
TAKEN WITHIN THE
PAST SIXTY (60) DAYS
DO NOT STAPLE PHOTO
Transparent tape at edges
is preferred
________________________________________ _________________________________________ _______________________________
Last Name First Name Middle Name
__________________________________________________________________________________________________________________
Other Names Used: (Provide copies of marriage license or court records). If this does not apply to you, write N/A.
__________________________________________________________________ ___________________________________________
Mailing Address Cell/Daytime Phone Number
__________________________________________________________________
Gender: Male Female
City State Zip
__________________________________________________________________
Email Address
Date of Birth: ___________________________ Social Security Number: _________________________________
If using FCVS for verification of education, training and
national medical
exam scores, Check here:
01/2018 Page 2
SECTION 2: ALTERNATE CONTACT
You may authorize someone else to check the status of your application by providing the following information and
signing below. If this section is blank, only you, the applicant, will be told the status of this application.
SECTION 3: SPONSORING ARIZONA LICENSED PHYSICIAN
In addition to providing the information below, the sponsoring physician (M.D. or D.O.) must submit a written request
pursuant to A.R.S. § 32-1823(A)(2) which includes the required information as stated in the LT application instructions.
To facilitate this request a form has been provided in the application packet (Sponsoring Physician: Written Request for
Locum Tenens Registration).
Name of
Sponsoring Physician:
Name of
Company/Practice:
Address:
City, State, Zip:
Exact Requested Dates of Locum
Tenens (not longer than 90 days):
Start Date:
____________________
End Date:
_____________________
SECTION 4: EDUCATION AND TRAINING HISTORY
Fill in the areas below completely and accurately. Please submit Form No. 1 to the Osteopathic College from which you
graduated and Form No. 2 to all program(s) at which you trained, regardless of completion. The form must be
completed by the Registrar’s Office and Program Director(s) respectively, and returned directly to the Arizona Board of
Osteopathic Examiners in order to provide verification of your training. If the facilities are now defunct, please so
indicate. If more space is needed, use a separate sheet.
Name of Institution
City/State
Years Attended
From/ To
Osteopathic College
Internship/PGY-1
Residency
Residency (if more
than one)
Fellowship
Name of Contact: _________________________________________ Phone Number: _______________________
Name of Company: _________________________________________ Email: _______________________________
Address: ____________________________________________________________________________________
City, State, Zip: _________________________________________________________________________________
I, _________________________________________________, give authorization for the above named person to be
informed of the status of my application for licensure in Arizona.
01/2018 Page 3
SECTION 5: NATIONAL MEDICAL EXAMINATION
List the national medical examinations you passed and dates. If you passed Level 3 of the COMLEX or Part 3 of the
USMLE exam in the past seven (7) years, you must provide proof you passed the exam as listed in the instructions. If it
has been more than seven (7) years since you passed your licensing examinations, you do not need to provide proof.
However, you still need to list the exams you passed in the table below:
Name of Exam / Part or level
Date passed
SECTION 6: STATE LICENSES
Fill in the information for each license you hold or have held. If you were previously licensed in Arizona, provide that
information also. Please use a separate blank sheet of paper if necessary to provide a complete list. Explain any time
you were not in practice. You must request that each state listed (except Arizona) send a verification of license directly
to the Arizona Board of Osteopathic Examiners.
Issuing State
License Number
Issue Date:
MM/DD/YY
Expiration Date:
MM/DD/YY
License Status
SECTION 7: FIELD OF PRACTICE/AREA OF INTEREST: ____________________________________________________
SECTION 8: PRACTICE EXPERIENCE
Provide a list of all health care facilities, clinics, urgent cares, offices, etc., at which you have practiced medicine,
consulted medicine or had staff privileges, whether employed or in private practice. This list must account for all years
since initial licensure. This does not include facilities at which you were doing PGT rotations. If more space is needed,
please use a separate blank sheet of paper. If this information is in your CV, you may write “see CV” in the table and
include your CV with your application instead.
Verification of the last seven (7) years of practice experience is required. Please send Form 3: Practice Experience
Verification to the appropriate entities in order to obtain this, and then have the completed form(s) sent directly to the
Board in order to maintain the integrity of the verification. We accept verifications by fax, email or mail from the
verifying entities only.
Start Date
(M/D/YYYY)
End Date
(M/D/YYYY)
Name of Health Care Facility or Employer
City/State
01/2018 Page 4
SECTION 9: PROFESSIONAL CONDUCT HISTORY
Failure to properly answer the questions below may result in Board disciplinary action including revocation of your locum tenens registration.
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a separate blank sheet
of paper
. As appropriate, attach copies of documents from hospitals, programs, State Boards, courts and law enforcement
agencies confirming your explanation.
YES
NO
1. Have you ever been arrested for, charged with or convicted of any felony, or any misdemeanor? You must answer “yes” even
if the offense occurred outside of Arizona, the case has not yet been adjudicated, you completed a diversion program, you
received a suspended sentence or probation, the convictions were dismissed or set aside, your sentence was commuted, the
records were expunged, your civil rights were restored or you received a pardon.
2. Have you had any disciplinary or adverse action imposed against any professional license, or were you denied a professional
license, or have you entered into any consent agreement, stipulated order, or settlement with any regulatory board; OR have
you have been notified of any complaints or investigations against your license that have not yet been resolved?
3. Has your DEA permit or prescription permit issued by any regulatory board been denied, restricted, suspended, lost, or had
any other adverse action taken against it, OR have you been notified of any complaints or investigations against your authority
to prescribe that have not yet been resolved?
4. Has any award, settlement, or payment of any kind been made by you or on your behalf to resolve a civil suit or malpractice
claim involving your practice, even if it was not required to be reported to the National Practitioner Data Bank; OR have you
been notified that any such suit or claim is pending?
5. Have your hospital privileges or health care program affiliations been denied, restricted, lost, suspended or modified, or
subjected to any other adverse action, even if that action was not required to be reported to the National Practitioner Data
Bank; OR have you been notified of any complaints against or reviews of your privileges or affiliations that have not yet been
resolved?
6. During an internship, residency, or fellowship program were you placed on probation, had your privileges restricted or
suspended, terminated from the program or had any other adverse action taken against your participation even if that action
was not required to be reported to the National Practitioner Data Bank?
SECTION 10: PROFESSIONAL CONDUCT HISTORY - CONFIDENTIAL QUESTIONNAIRE
SECTION 11: ATTESTATION TO BE SIGNED BY APPLICANT AND NOTARIZED
I attest that all information submitted on or with this application is true. I am the person named on this application. I have read the statutes and
rules regarding licensure and have read the complete application, know the full content thereof, and declare that all of the information contained
herein and evidence or other credentials submitted herewith are true and correct. I am not omitting any information which might be of value to
this Board in determining my qualifications. I acknowledge that any falsification, omission, or withholding of information or facts concerning my
qualifications as an applicant shall be sufficient to deny licensure or constitute grounds to revoke, suspend or cancel the license, if not discovered
until after issuance. A.R.S. §§ 32-1822, -1854(9).
___________________________________________________, D.O. _________________________________
Signature of Applicant Date Signed
State of _______________________ )
)
County of _______________________ )
On this ______ day of ______________, 20_____ before me personally appeared ______________________________________(applicant), known
to me or whose identity is proved to me by satisfactory evidence to be the person who he/she claims to be and who swore or affirmed before me
that the information in this application is true, complete and correct.
Notary Public: __________________________________________
SEAL
My commission expires: ______________________________
If you answer “yes” to either of the following questions, you must submit a detailed written narrative statement
concerning matter(s) including the name of the healthcare providers and treatment centers where you were treated along
with the discharge summary of your treatment and progress. If you are currently participating or have participated in a
confidential agreement or order in a program for the treatment and rehabilitation of doctors of osteopathic medicine
impaired by alcohol, drug abuse or for other issues, please submit a copy of the agreement/order along with compliance
reports from the state monitoring programs.
YES
NO
1. Have you been diagnosed with or developed initial or worsening symptoms of a physical, mental or emotional condition
which did or may impair or limit your ability to safely practice medicine?
2. Have you entered into a diversion program for evaluation, treatment or monitoring for substance abuse or dependency or
for correction of communication or boundary issues, in lieu of or as a condition of resolving a matter before a regulatory board,
criminal or civil court; OR have you been notified that such action is pending? You must answer “yes” even if you received a
pardon, the convictions were set aside, the records were expunged, your civil rights were restored and whether or not the
sentence was imposed or suspended.
01/2018 Page 5
ARIZONA STATEMENT OF CITIZENSHIP
AND ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Permit
Arizona Board of Osteopathic Examiners in Medicine & Surgery
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) _____________________________________________________
TYPE OF APPLICATION (Check one) INITIAL APPLICATION RENEWAL
TYPE OF LICENSE/PERMIT (Check one) DO PGT Locum Tenens
SECTION II – CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a citizen or national of the United States? Yes No
If Yes, indicate place of birth:
City ______________________________ State (or equivalent) _________ Country or Territory _______________________
If you answered Yes, 1) Attach a legible copy of one or more document(s) from the attached
"Evidence of U.S. Citizenship, U.S. National Status or Alien Status" page.
Name of document ___________________________________________
2) Go to Section IV.
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 legible copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S. National
Status or Alien Status". Name of document provided _____________________________________________________________.
01/2018 Page 6
Qualified Alien Status (8 U.S.C. §§ 1621(a)(1),-1641(b) and (c))
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.
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
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).
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA
Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
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.
Otherwise Lawfully Present
14. A person not described in categories 1-13 who is otherwise lawfully present in the United States. PLEASE NOTE: The
federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons who fall into this
category ineligible for licensure. See 8 U.S.C. § 1621(a).
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
click to sign
signature
click to edit
01/2018 Page 7
EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS OR ALIEN STATUS
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. If proof of legal status does not include a photo, a copy of a current government issued photo ID such as a
driver’s license or US passport is required.
Evidence showing authorized presence in the United State includes the following:
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.
3. A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (on
or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa or the Northern
Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local time)
4. A United States certificate of birth abroad.
5. A United States passport. ***Passport must be signed***
6. A foreign passport with a United States visa.
7. An I-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization document or refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or Bureau of Indian Affairs affidavit of birth.
13. Any other license that is issued by the federal government, any other state government, an agency of this state or a political
subdivision of this state that requires proof of citizenship or lawful alien status before issuing the license.
01/2018 Page 8
Fingerprinting Required
(A.R.S. § 32-1822(A)(9))
Effective September 1, 2017, fingerprinting/background checks are required for the following
applications:
• Initial (New) License
• Teaching License
• Locum Tenens Registration
All applicants will receive a packet from the Board that will detail the steps the applicant must take to
comply with the fingerprint process. Please note that the fingerprint card is specific and pre-printed for
this Board; therefore, the applicant must use the fingerprint card provided by the Board or fingerprint
card FD-258 to include the same pre-printed information within each blue box.
The fingerprint technician is required to fill out and date the identity verification form, place the identity
verification form and the completed fingerprint card into the envelope, and seal the envelope closed.
Once the envelope is sealed, the technician will return the envelope to the applicant. They applicant
must mail or deliver the sealed envelope to the Board office.
Failure to return the sealed envelope with the fingerprint card and identity verification form enclosed
will result in a delay in processing your application. If you have further questions, please review the
Fingerprinting FAQ on the website.
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
_________________________________________________________________________________________________________________________
Page 9
01/2018
Form No. 1: PROFESSIONAL EDUCATION VERIFICATION
In applying for a locum tenens registration in Arizona, the Arizona Board of Osteopathic Examiners requires this form be
completed by the Dean or the Registrar of the osteopathic medical school from which you graduated. This is authorization to
release any information in your files of record, favorable or otherwise, DIRECTLY to the ARIZONA BOARD OF OSTEOPATHIC
EXAMINERS, 1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007.
Applicant Name: _________________________________________________________, D.O. Last 4 digits of SSN: ______________
Signature _____________________________________________________ Date (Month/Day/Year)__________________________
_____________________________________________________________________________
THIS SECTION TO BE COMPLETED BY AN OFFICIAL OF THE OSTEOPATHIC MEDICAL SCHOOL
This certifies that __________________________________________________________________________ , D.O.
(Name of Applicant)
was enrolled in: ___________________________________________________________________________________________
(Name of Osteopathic College of Medicine)
__________________________________________________________________________________________
(Location – City/State)
The undersigned further certifies that the records of this institution show that the applicant was granted an Osteopathic Medical
Degree by the above named COM on: _____________________________ Date (Month/Day/Year)
COMMENTS: ________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Signature: ______________________________________________________________________________ Date: ______________________________________
Name Typed or Printed: _____________________________________________________ Title: _____________________________________________________
Address: __________________________________________________________________________ Phone No.: ______________________________________
City/State/Zip: _________________________________________________________________ Fax No.: ___________________________________
Contact person, if different than above: ___________________________________________________________________________________________
Email: _____________________________________________________________________________________________________________________
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
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
Page 10
01/2018
Form No. 2: POSTGRADUATE TRAINING VERIFICATION
FOR APPLICANT: Make as many copies as needed. Mail or fax this form to the program director of each postgraduate training (PGT) program in which you
participated regardless of completion. This completed form is a requirement of locum tenens registration in Arizona. Your signature below is authorization to
release any information about you in your PGT program’s files of record, favorable or otherwise DIRECTLY to the Arizona Board of Osteopathic Examiners in
Medicine and Surgery.
Applicant Name: ___________________________________________________________________________________________, D.O.
Signature _____________________________________________________________________ Date (Month/Day/Year) ___________________________________
THIS SECTION TO BE COMPLETED BY PROGRAM DIRECTOR
FOR PGT PROGRAM DIRECTOR: The above named individual has applied for a locum tenens registration in Arizona and has stated that he/she has participated
in a PGT program at your facility. He/she is required to submit this form to you for completion. Therefore, please complete this form and return it to our office at
the address above.
1. Important – Program Participation: Please report internships, residencies and fellowships separately. Please report incomplete postgraduate years (PGY)
separately from those successfully completed. If the postgraduate year is currently in progress, report the expected completion date in the “To” field.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
From: __________/__________/_________ To:__________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
From: __________/__________/_________ To: __________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY:__________________________________________________________________________________
From: __________/__________/_________ To: __________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2. The following questions apply to the PGT years stated above. Please check the appropriate response.
a. This program was approved for postgraduate training during this individual’s attendance by: AOA ACGME DUAL
b. Did this individual ever take a leave of absence or deferment/break from his/her training? Yes No
c. Was this individual disciplined and/or placed under investigation or on probation? Yes No
d. Did this individual participate in a confidential or public diversion program for substance abuse monitoring? Yes No
Please explain below any “Yes” response(s) to the questions above. Use a separate blank sheet of paper if more room is necessary.
3. COMMENTS: ________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Signature: ______________________________________________________________________________ Date: __________________________________________
Name Typed or Printed: ___________________________________________________________________ Title: __________________________________________
Full name of Program or Hospital: __________________________________________________________________________________________________________
Address: ________________________________________________________________________ Phone No.: ____________________________________________
City/State/Zip: ___________________________________________________________________ Fax No.: ____________________________________________
Contact person, if different from above: ______________________________________________ Email: ________________________________________________
Arizona Board of Osteopathic Examiners In Medicine and Surgery
9535 E. Doubletree Ranch Road, Scottsdale, AZ 85258
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
______________________________________________________________________________________________________________________________________________________________
Internship
Residency
Fellowship
Internship
Residency
Fellowship
Internship
Residency
Fellowship
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Page 11
01/2018
Form No. 3: PRACTICE EXPERIENCE VERIFICATION
In applying for a locum tenens registration in Arizona, the Arizona Board of Osteopathic Examiners requires this form be completed by the Medical
Employer/Director where I have practiced medicine for evaluation of my professional record and mental and physical capabilities during the seven (7)
years preceding my application. This is authorization to release any information in your files of record including a standard affiliation verification letter
DIRECTLY to the Arizona Board of Osteopathic Examiners, 9535 East Doubletree Ranch Road, Scottsdale, AZ 85258. Faxed verifications are acceptable if
accompanied by a coversheet bearing your facility’s logo or letterhead.
Applicant Name: ______________________________________________________________________________________, D.O.
Signature ____________________________________________________________ Date (Month/Day/Year) _________________________
_____________________________________________________________________________
THIS SECTION TO BE COMPLETED BY FACILITY OFFICIAL
1. This is to certify that __________________________________________________________________________________________, D.O.,
held/holds the following position: _____________________________________________________________________________________
Dates: From: _________________________________________ To: _________________________________________
Month/Day/Year Month/Day/Year
Circle the correct response to the questions below: (“Yes” responses require written explanation.)
2. Has this individual participated in a confidential or public diversion program for substance abuse monitoring? Yes No
3. Was this individual disciplined and/or placed under investigation or on probation? Yes No
Please explain below any “Yes” response(s) to the two questions above.
Use a separate blank sheet of paper if more room is necessary.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Practice/Facility: _______________________________________________________ Phone No: ___________________________________
Address: _________________________________________________________ Fax No.: ____________________________________
City/State/Zip: _________________________________________________________ Email: ______________________________________
Name of Official (printed): _______________________________________________ Title: _______________________________________
Signature: ___________________________________________________________________ Date: ______________________________
.
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
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
______________________________________________________________________________________________________________________________________________________________
Page 12
01/2018
Arizona Board of Osteopathic Examiners LT Registration Application
MALPRACTICE CLAIM / SUIT QUESTIONNAIRE
Complete the information below for each instance of any award, settlement or payment of any kind either made by you or on
your behalf to resolve a civil suit or malpractice claim involving your practice even if it was not required to be reported to the
National Practitioners Data Bank; OR if you have been notified that any such suit or claim is pending. Duplicate this form as
necessary and use as a cover sheet with all supporting documentation required.
1. Applicant’s name: ________________________________________________________________________
2. Name of patient: _________________________________________________________________________
Last name First name Middle name/initial
3. Date of occurrence: ________________________________
4. Location of occurrence: ___________________________________________________________________
Name of hospital / office / clinic) City / State
5. Current status of suit/claim: Pending Settled
If settled, was it settled: in court out of court Date of settlement: ______ /______ /______
6. Total Amount of Settlement / Award $________________ Amount attributable to you $_________________
7. Name of your insurance company: ____________________________________________________________
8. Has this case been investigated or reviewed by any state board? No Yes Pending
If Yes or Pending, name of Board: ____________________________________________________________
What was the outcome? Please include a copy of the final disposition:
_______________________________________________________________________________
9. On a separate sheet of paper, in your own words, briefly describe the claim / suit and your involvement. Attaching
the NPDB description is not an acceptable response.
10. Attach the following documents to this form. Your application will not be decided upon until the following
attachments have been received:
a. plaintiff’s complaint or claim to insurer;
b. settlement agreement, court order or dismissal letter (if case has concluded) and
c. Board resolution after investigation of case (if case has concluded).
__________________________________________________________ __________________________
Signature of applicant Date signed
Completed form and documentation may be faxed to Board office at 480-657-7715
Page 13
01/2018
Sponsoring Physician: Written Request for Locum Tenens Registration
To be completed by the Arizona licensed doctor of osteopathic medicine (D.O.) or doctor of medicine (M.D.)
requesting locum tenens registration of the applicant in accordance with A.R.S. § 32-1823.
1. Name of Locum Tenens Applicant: ____________________________________________________________, D.O.
2. Applicant will be providing locum tenens medical services to (check one):
SUBSTITUTE FOR the sponsoring physician
TEMPORARILY ASSIST the sponsoring physician
3. Exact Start Date for which Locum Tenens is requested: _______________________________ (month, day, year)
Granted Locum Tenens registration is valid for ninety (90) days and may be extended once for an additional ninety
(90) days upon written request from the sponsoring physician who originally initiated the request for this registration.
The written request must state the reason for the extension. Submit the appropriate fees and other documents
requested by the Executive Director.
4. Name of Sponsoring Physician (print): _________________________________ Arizona License No.: ___________
5. Sponsoring Physician Contact Information:
Name of Practice
Address
Address
City, State and Zip
Phone Number
Fax Number
6. __________________________________________________ D.O. M.D. Date: ___________________
Signature of Arizona Licensed Sponsoring Physician (circle one)
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
______________________________________________________________________________________________________________________________________________________________
Page 14
01/2018
90-Day Locum Tenens (LT) Registration Application Checklist
LT Application packets with original notarized signatures must be mailed or delivered to the Board office.
Scanned or faxed applications are not acceptable.
BEFORE YOU SEND US YOUR LOCUM TENENS REGISTRATION APPLICATION PACKET,
CHECK THAT YOU HAVE COMPLETED THE FOLLOWING:
1. A completed and notarized current version of the Board’s registration application. Please download the
current version from our website at www.azdo.gov > For DOs > Applications.
2. $300 application fee. We accept Visa, MasterCard, American Express check or money order. If paying by
credit card, please use the credit card payment form included in the application packet. Make your check
or money order payable to the Arizona Board of Osteopathic Examiners.
3. Written request from the sponsoring M.D. or D.O. licensed in Arizona for whom you are substituting or
assisting (see instructions for details).
4. Copy of government issued picture ID (e.g., current driver’s license or US passport) showing same name as
used on application.
5. Completed Arizona Statement of Citizenship Status form and copy of government issued documentation
showing citizenship or resident alien status (e.g., current US passport, birth certificate, naturalization
certificate, green card, etc.).
6.
Copy of legal documentation showing change of name, if applicable.
7. Explanations and supporting documentation of all “yes” answers to Professional Conduct History
questions. This includes medical malpractice settlements, etc. Use the form “Malpractice Claim/Suit
Questionnaire” as a coversheet for each instance of medical malpractice.
8. Copy of your diploma or transcript from an approved College of Osteopathic Medicine (COM) showing the
date of your graduation. Sent Form No. 1 to your COM for verification.
9. Copy of certificate or official letter showing completion of your internship or first year of residency. Sent
Form No. 2 to all programs at which you trained, regardless of completion.
10.
Proof that you passed the national osteopathic medical examination(s).
11. Sent Form No. 3 to all facilities where you practiced medicine in the last seven (7) years for verification.
12.
Requested verification of licensure and disciplinary history from each state in which you are or
have been
licensed be sent to the Arizona Board of Osteopathic Examiners.
13. Applicants for a locum tenens registration are required to undergo a background check. You will be sent a
fingerprint packet after your application has been received by the Board. Follow the instructions in the
packet. Fingerprint cards cannot be accepted prior to the application. No fingerprint fee is required at
this time.
Do not include this checklist with your application. Its purpose is to help you complete the paperwork associated with licensure and
submit a satisfactory application, thereby preventing unnecessary delays. Please call the licensing division or email with any
questions: 602-771-2525.
Page 15
01/2018
CREDIT CARD PAYMENT AUTHORIZATION FOR
OSTEOPATHIC LOCUM TENENS REGISTRATION APPLICATION FEE
Name of Applicant: _______________________________________________________________________, D.O.
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
______________________________________________________________________________________________________________________________________
Please complete and mail with your application if paying by credit card.
Amount: $300.00
Type of Card: Visa MasterCard American Express
Visa or MasterCard #: _________________
- _______________ - _______________ - _______________
OR
American Express #: _________________ - ___________________________ - ___________________
Expiration Date: ___________
/ ___________ (MM/YY)
Name as Shown on Payment Card: ___________________________________________________________________
Billing Address: (Required)
Street Address: ___________________________________________________________________________________
City: ________________________________________________________ State: _________ Zip: _________________
Phone Number of Card Holder: (Required) _______________________________________________________
Mailing Address (Required if different from billing address)
Street Address: ___________________________________________________________________________________
City: ________________________________________________________ State: _________ Zip: _________________
Phone Number of Card Holder: (Required) _______________________________________________________
Signature of Cardholder: ___________________________________________________ Date: ________________________
Note: The Board shreds this form after payment has been authorized by your credit card company
Page 16
01/2018
Locum Tenens Registration Application
Processing Overview
YOU HAVE SUBMITTED YOUR APPLICATION, WHAT HAPPENS NEXT?
EMAIL ACKNOWLEDGEMENT: When Board staff has received your application packet, you will be sent an email acknowledging
receipt. If you do not provide an email address, no acknowledgement will be sent. This acknowledgement does not mean that
all required documents have been received.
FINGERPRINT PACKET: As of September 1, 2017, locum tenens registration applicants are required to undergo fingerprinting per
A.R.S. § 32-1823 and § 32-1822(A)(9). A fingerprint packet will be sent to you at the mailing address you provided on your
application. Follow the instructions in the fingerprint packet to avoid delays or having to repeat submission of your fingerprints.
Your application will remain administratively incomplete until the fingerprint processing is complete.
ADMINISTRATIVELY COMPLETE/DEFICIENCY LETTER: Within thirty (30) days after receipt of the application, staff will mail a
letter to you listing the missing or incomplete information needed to complete your application.
If all the documents on the checklist have been received, you will not receive this letter.
ADMINISTRATIVELY COMPLETE: After everything on the checklist has been received, the Board staff will independently obtain
the following:
1. National Practitioner Data Bank report
2. Federation of State Medical Board’s Practitioner Profile
At this point your application is administratively complete and moves to substantive review.
SUBSTANTIVE REVIEW: This stage of the application process is the evaluation of all answers, documents, and verifications
collected and the decision whether they demonstrate you are qualified for the locum tenens registration. You may be required
to appear before the Board at a regularly scheduled Board meeting for a decision on your application.
ISSUANCE OF LOCUM TENENS REGISTRATION: If, at the conclusion of the substantive review, your application is approved, you
will receive a letter by email and regular mail letting you know your Locum Tenens Registration has been issued. Your
registration number, effective date, and expiration date are also provided. Included with the letter is a copy of the issuance
letter and registration certificate sent to your sponsoring physician.
As of the effective date of registration you may assist or substitute for the sponsoring physician. A Locum Tenens Registration
does not authorize you to practice medicine independently in Arizona. If you want to practice in Arizona at a facility or location
other than your sponsoring physician’s practice location(s), you will need to obtain full licensure.
If your sponsoring physician wants you to continue assisting or substituting for him/her after the expiration date, the sponsoring
physician must send a written request stating the reason for the extension. Another $300 fee must be paid in order to extend
the registration for another 90 days. This request may be sent to the Board office by fax, email, or regular mail.
Arizona Revised Statutes and Rules for osteopathic licensure can be found on our website at www.azdo.gov
> Statute and Rules.
As a Locum Tenens registered physician, you will be subject to all state and local laws and regulations pertaining to public health
and subject to all the same duties and obligations and authorized to exercise all the same rights and privileges possessed by
physicians and surgeons of other complete schools of medicine in the practice of their profession per A.R.S. § 32-1852.
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LOCUM TENENS REGISTRATION APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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Completed 20 July 2020

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