Arizona Medical Board
Patricia McSorley, Executive Director
  • Find your MD/Resident/Temp License
  • Licensure
  • Regulation
  • For Consumers
  • Laws & Rules
  • MD Center
  • Forms
  • Medical Assistant
  • Find your MD/Resident/Temp License
  • Licensure
  • Regulation
  • For Consumers
  • Laws & Rules
  • MD Center
  • Forms
  • Medical Assistant
Forms
  • Forms
Forms List

Adjudication Process Document AMB
Guidelines for CAM
The Arizona Medical Board's Guidelines for Physicians Who Incorporate or Use Complementary or Alternative Medicine in Their Practice.
Application Fee Waiver Fillable Form
provides a financial waiver of application fees for qualified applicants. If you qualify to apply as a Medical Doctor, you may be eligible for the waiver. Applicants must have a family income not exceeding 200% of the federal poverty guidelines. If you believe you qualify for the waiver, complete the application fee waiver form and provide the required documents
Application Fee Waiver Instructions
Instructions for the Application Fee Waiver Form
Application Fee Waiver Static Form
provides a financial waiver of application fees for qualified applicants. If you qualify to apply as a Medical Doctor, you may be eligible for the waiver. Applicants must have a family income not exceeding 200% of the federal poverty guidelines. If you believe you qualify for the waiver, complete the application fee waiver form and provide the required documents.
Breast Implant Consent Checklist
Citizenship Statement
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.
Clinical Instructor Verification Form
CME Audit Form
Combined CME Table effective 09/06/2019
Complaint and Investigation Process Summary
Data Disk Order Form
To order a CD-ROM containing the Physician and Physician Assistant Database, download this printable form which includes detailed instructions|(Providing an electronic medium containing public information about licensed physicians: $100.00*)
Data Waiver Eligibility Application
Data Waiver Eligibility Application - Fillable
Dispensing Registration Application
Evidence List - as referenced for the full MD license application
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).
Instructions for Completing the Cause-of-Death Section of the Death Certificate
Jury Duty Medical Excuse Form
Should a patient requests that they be excused from jury service for reasons related to mental or physical conditions
Legal Name Change Form
License Verification Request Form
(Verifying a license: $10.00 per request*)
Locum Tenens Application
MD Complaint
MD Duplicate License Form
MD Education Teaching Permit - Payment Form
MD Pro Bono List
MD Resident List
MD Telehealth License List
MD Temporary License Application
MD Temporary License List
MD Universal Recognition License Application - Fillable
Medical Assistant FAQs
Medical Directory Download
Downloadable Physician and Physician Assistant Directory
Medical Directory Order Form
(Providing a copy of annual allopathic medical directory: $30.00*) Use this form to request a Physician and Physician Assistant Directory
Misc. Evidence List
Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office
Notice of Exempt Final Rulemaking Article 2 Licensure
Notice Requirements Form
Notice to Patients Form
"A.R.S. 32-1401(26)(gg) 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.
Office Based Surgery Rule Clarification
Online Application Checklist and Required Supplemental Forms
Physicians' Handbook on Medical Certification of Death
Postgraduate Training Permit Registration
Printable Initial Application
MD Paper Renewal
Use the MD Paper Renewal Form if you would like to print and mail your application. Please allow 4-6 weeks for the processing of paper renewals.
Pro Bono Application
Pro Bono Reapplication
Proper Termination of Patients Guidelines
These Guidelines should assist providers in assessing their responsibilities when deciding to terminate the physician-patient relationship.
Public Information Request Form
To request public information, download this printable form which includes detailed instructions|(Providing a copy of records, documents, letters, minutes, applications, and files, $1.00 for the first three pages and $0.25 for each additional page*)
Reactivation Application
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.
Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain in the Office Setting
Reportable Misdemeanors
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.
Request For Inactivation Or Cancellation
Prior to submitting your request please read the following statutes regarding the qualifications of Inactivation or Cancelation of your Arizona medical license.
Responsibilities of Health Care Providers when Certifying Death Records
Legal requirements for individuals performing medical certification of death
Responsibilities of Health Care Providers when Certifying Death Records
Legal requirements for individuals performing medical certification of death
Scope of Practice Guidelines
Arizona Medical Board Scope of Practice Guidelines
Summary of Medical Graduate Training Permit Process
Teaching License Application
Teaching License Reapplication
Telehealth Registration Application
Temporary Emergency License for COVID-19
*Initial approval of a temporary emergency COVID-19 license expires after 90 days. | **Upon renewal of a temporary emergency license, the license will be in effect until Governor Ducey declares an end to the state of emergency in Arizona.
Temporary License Language
The Board's Complaint Process
Transitional Training Permit
Transitional Training Permit Roster
Your Medical Records Rights in Arizona
Your Medical Records Rights in Arizona

State of Arizona Seal
      Contact Us
Arizona Medical Board
   Address:   1740 W Adams St, Suite 4000
Phoenix, AZ 85007
   Hours:   8am - 5pm Mon - Fri
   Phone:   (480) 551-2700
   Toll Free:   (877) 255-2212
   Fax:   (480) 551-2702
   Email:   Contact the Board
OCCUPATIONAL REGULATION

Pursuant to section 41-1093.01, Arizona Revised
Statutes, an agency shall limit all occupational
regulations to regulations that are dememonstrated to
be necessary to specifically fulfill a public health,
safety or welfare concern. Pursuant to sections 41-
1093.02 and 41-1093.03, Arizona Revised Statutes,
you have the right to petition this agency to repeal or
modify the occupational regulation or bring an
action in a court of general jurisdiction to challenge
the occupational regulation and to ensure
compliance with section 41-1093.01, Arizona
Revised Statutes.

Arizona Medical Board Location Map Image






The Ombudsman-Citizens Aide
helps citizens to resolve ongoing issues with state agencies.
 
Privacy Policy
Accessibility Policy
Glossary
Employment
Open Books
 
 
 
 
 
© Copyright 2016 - 2022 azmd.gov. All rights reserved.