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 | |
PLEASE NOTE: You are required to send copies of your CME Activity Report(s) or Certificates of Completion with this form.
hysician Name: ______________________________________________________________ AZ Lic # ______________________
Daytime Phone #: ____________________________ Email : _______________________________________________________
1. The Executive Director will decide on your request within seven (7) days. The written response will be sent to
you at the
mailing address you have on file with the Board.
2. Filing this Request for Waiver does NOT exempt you from having to pay penalty fees in addition to the renewal fee if your
renewal application is submitted after January 31, 2019.
3. You must submit your Request for Waiver no later than January 30, 2019. Waivers cannot be accepted after this date.
4. Your renewal application form, renewal fee (and penalty fee if needed) must be received before midnight April 30, 2019.
If you do not complete your renewal, your license will expire May 1, 2019 and you may not practice in Arizona until you re-
apply as a new applicant, your application is approved and your new license is issued.
My renew by date is December 31, 2018. In submitting and signing this form, I am requesting a waiver of the CME requirement
for my Arizona license renewal. I attest that I have read and understand the above requirements for obtaining a waiver and
renewing my license if/when my waiver request is approved.
Physician Signature: ________________________________________________________ Date signed: _______________________
A. How many hours of AOA accredited Category 1-A CME hours have you taken to meet the forty (40) hour
requirement? ______________ (January 1, 2017 December 31, 2018)
B. How many hours of other AOA CME or ACCME accredited AMA Category 1 CME hours have you taken to meet
the forty (40) hour requirement? ______________ (January 1, 2017December 31, 2018)
C. As allowed by A.R.S. § 32-1825(C), I hereby request a waiver from completing the CME requirement of 40 hours in
the two (2) years preceding this renewal of my license for the reason(s) checked below. I have attached the listed
documentation as required by the Board’s rules (AAC R4-22-207).
Disability: Attach letter from your treating physician stating nature of disability.
Military service: Attach a copy of your current orders or a letter on official letterhead from your commanding
Absence from the United States: Attach a copy of the pages from your passport showing exit and reentry dates.
Other circumstances beyond my control: Attach a letter stating the nature of circumstances. Attach
documentation that provides evidence of the circumstances.