T:\Licensing\New License Applications and forms\Form\Revised 2018 01.12.2018
ARIZONA MEDICAL BOARD
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Telephone: 480- 551-2700 - Toll Free: 877-255-2212 - Fax: 480-551-2704
Website: www.azmd.gov - E-Mail: questions@azmd.gov
License Status Change Request Form
First Name: Last Name:
License Number:
Practice Address:
City:
State:
Zip Code:
Phone: Fax:
Mailing Address:
City:
State: Zip Code:
Home Address:
City: State: Zip Code:
Please check if your home and mailing address are the same:
Yes No
Required
Email:
Phone:
I request INACTIVATION of my medical license. A.R.S. § 32-1431
A. A person holding a current active license to practice medicine in the state may request an inactive license from the board if both of the following are
true:
1. The licensee is not presently under investigation by the board.
2. The board has not commenced any disciplinary proceeding against the licensee.
B. The board may grant an inactive license and waive the renewal fees and requirements for continuing medical education specified by section 32-1434
if the licensee provides evidence to the board's satisfaction that the licensee has totally retired from the practice of medicine in this state and any state,
territory and district of the United States or any foreign country and has paid all of the fees required by this chapter before the request. The board may
grant pro bono registration pursuant to section 32-1428 to physician who holds an inactive license under this section.
C. During any period in which a medical doctor holds an inactive license, that person shall not engage in the practice of medicine or continue to hold or
maintain a drug enforcement administration controlled substances registration certificate, except as permitted by a pro bono registration pursuant to
section 32-1428. Any person who engages in the practice of medicine while on inactive license status is considered to be a person who practices
medicine without a license or without being exempt from licensure as provided in this chapter.
D. The board may convert an inactive license to an active license if the applicant pays the renewal fee and presents evidence satisfactory to the board
that the applicant possesses the medical knowledge and is physically and mentally able to safely engage in the practice of of medicine. the board may
require any combination of physical examination, psychiatric or psychological evaluation or successful passage of the special purpose licensing
examination or interview it finds necessary to assist it in determining the ability of a physician holding an inactive license to return to the active practice
of medicine.
Please be aware that upon approval of your request, you will not be able to practice medicine until you convert your inactive license
to an active license pursuant to A.R.S. § 32-1431 (D), or apply for pro bono registration pursuant to A.R.S. § 32-1428.
I request CANCELLATION of my medical license. A.R.S. § 32-1433
On request of an active licensee, the board may cancel that person's license if both of the following are true: 1. The licensee is not presently under
investigation by the board. 2. The board has not commenced any disciplinary proceeding against the licensee.
Date:
Signature:
I hereby attest that I meet the requirements to change the status of my license to practice in Arizona.
