PUBLIC INFORMATION REQUEST FORM
Arizona Medical Board
Arizona Regulatory Board of Physician Assistants
1740 W. Adams St, Suite 4000, Phoenix, AZ 85007
Phone (480) 551-2700 Fax (480) 551-2702 www.azmd.gov
Fax Number:Phone Number:
Public Information Requested
List physician or
name or license
List agendas or
Please check one of the following:
I want to receive the documents via e-mail at no cost.
I am requesting papers copies of the public information. Paper copies are $1.00 for the first three pages and $0.25 for
each additional page. If requesting paper copies, you will receive an invoice.
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.
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