This form is to be completed by the applicant and is to be submitted for every application, permit or registration that is offered by the Arizona Medical Board,
with the exception of the renewal of license if citizenship has previously been established with the Board.
As a requirement for licensure in Arizona, United States citizens must provide a notarized copy of their birth certificate or notarized copy of their passport
in accordance with A.A.C. R4-16-201(C)(1). Non-citizens must provide proof of immigration status in accordance with A.R.S. § 41-1080 (see Evidence List) in addition
to a notarized copy of their birth certificate or passport, A.A.C. R4-16-201(C)(1).
<span>Misdemeanor offenses that have been determined to affect patient safety and are reportable under A.R.S. § 32-3208 by a licensee or license applicant.</span><br />
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<span>Other misdemeanors reportable under A.R.S. § 32-3208 besides those specifically listed within this document include any comparable charges filed against an Arizona licensee or license applicant by any other state, territory or country.</span>
"A.R.S. 32-1401(26)(ff) requires that a physician notify a patient of any financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient."
The statute requires that a physician use this Board prescribed form.
Note: This application may only be utilized if your license status is currently ‘Inactive’. You may not use this application if your license is currently Expired or Cancelled.
Misdemeanor offenses that have been determined to affect patient safety and are reportable under A.R.S. § 32-3208 by a licensee or license applicant.
Other misdemeanors reportable under A.R.S. § 32-3208 besides those specifically listed within this document include any comparable charges filed against an Arizona licensee or license applicant by any other state, territory or country.
Prior to submitting your request please read the following statutes regarding the qualifications of Inactivation or Cancelation of your Arizona medical license.