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 | |
Physician’s Name_________________________________________________ AZ License Number ___________________
Practice Name _______________________________________________________________________________________
Street Address _______________________________________________________________________________________
City _______________________________________________________________ State_________ Zip _______________
Phone No. _______________________________________ Fax No. _______________________________________
Email Address ____________________________________ If change of address, please check here
1. Complete this form and send it to the Board by midnight January 30, 2019. Extension requests cannot be accepted
after January 30, 2019.
2. The following must be sent with your request for extension:
proof of CME completed since January 1, 2017 and
proof of registration for additional CME needed to
meet renewal requirements.
3. Board approved CME hours taken during this extension period may be counted for only ONE renewal cycle. The
hours you apply to this renewal cannot be applied to your next CME renewal requirement.
4. By filing this extension you will automatically be included in the CME Audit and must complete and submit the CME
Audit Reporting Form AFTER you have completed the required forty (40) hours of CME. Twenty-four (24) of the forty
(40) CME hours must be AOA Category 1-A. The remaining balance of sixteen (16) hours may be any category including
AMA Category 1.
5. When submitting the CME Audit Reporting Form you must provide proof of completion of CMEs by sending a copy of
your AOA CME Activity Report or your certifying Board’s CME activity report verifying completion of at least forty (40)
CME hours in Board approved categories. For CME not accounted for on the above reports, please send copies of your
Certificates of Completion (do not send originals). Registration and receipt of payment for CMEs are not proof of
completion. CMEs completed prior to January 1, 2017 cannot be used for this renewal.
6. You may submit your Renewal Application Form and renewal fee (online or by paper) at any time through April 30, 2019. Please
renew your license prior to February 1
to avoid the late renewal penalty fee of $175 in addition to the renewal fee.
My renew by date is December 31, 2018. In submitting and signing this form, I am requesting an extension to April 30,
2019 to complete the required CMEs for my Arizona license renewal. I attest that I understand the above
requirements for renewing my license if/when my extension is approved.
Physician Signature: _____________________________________________________ Date signed: __________________
License holder must sign the form
Please read carefully. Your license is not renewed until the following steps are completed.
If you do not complete the Renewal Application Form and pay the renewal fee (and late fee if applicable) by
midnight April 30, 2019, your license will expire on May 1, 2019. You will not be permitted to practice in Arizona
until you re-apply as a new applicant, the application is approved and your new license is issued. The application
process may take up to six (6) months and is not a guarantee of re-licensure.
If you do not complete the CME Audit and submit proof of completion by midnight April 30, 2019, you may be required
to appear before the Board.