T:\Licensing\New License Applications and forms\New License Application\MD PA Application\Revised 2018\01.24.2018
ARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS
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.azpa.gov - E-Mail: firstname.lastname@example.org
License Status Change Request Form
First Name: Last Name:
State: Zip Code:
City: State: Zip Code:
Please check if your home and mailing address are the same:
I request INACTIVATION of my medical license. A.R.S. § 32-2528
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 if the person certifies total retirement form the performance of health care tasks in the state, any jurisdiction
of the United states and any foreign country and is current on all fees required by this chapter.
C. An inactive licensee shall not perform health care tasks.
D. The board may convert an inactive license to a regular license on payment of the annual renewal fee and
presentation of evidence to the board that the holder possesses the medical knowledge and the physical and mental
ability to safely engage in the performance of health care tasks. The board may require any combination of physical
examination, psychiatric or psychological evaluation, oral competency examination or a board qualified written
examination or interview it believes necessary to assist it in determining the ability of a physician assistant who holds an
inactive license to return to regular licensure.
I request CANCELLATION of my medical license. I am not presently under investigation by the Board, the Board has not
commenced disciplinary proceedings against me, and I am no longer practicing medicine in Arizona.
I hereby attest that I meet the requirements to change the status of my license to practice in Arizona.