A. An applicant for a pro bono registration
to practice medicine for a maximum of 60 days in a calendar year in Arizona
shall submit the following information on an application form available on
request from the Board and on the Board's web site:
1. Applicant's full name, social security
number, business and home addresses, primary e-mail address, and business and
home telephone numbers;
2. List of
all states, U.S. territories, and provinces in which the applicant is or has
been licensed to practice medicine;
3. A statement verifying that the applicant:
a. Agrees to render all medical services
without accepting a fee or salary; or
b. Agrees to perform only initial or
follow-up examinations at no cost to the patient or the patient's family
through a charitable organization,
B. In addition to the application form
required under subsection (A), an applicant for a pro bono registration to
practice medicine shall submit documentation listed under A.R.S. §
41-1080(A) showing that the applicant's presence in the
U.S. is authorized under federal law.
1.
Certified copy of the applicant's medical degree
diploma;
2.
Certified copies of internship, residency, or
fellowship certificates;
3.
Photocopy of any current license to practice
medicine in another state, territory, or possession of the United States or the
District of Columbia, along with a letter from the medical board issuing the
license, certifying that the license is current and in good
standing;
4.
Certified copy of ECFMG certificate, if
applicable;
5.
The fee required in A.R.S. §
32-1436 .
C. An applicant may make
application for a pro bono registration annually. A previously registered
applicant may apply for a pro bono registration by submitting the following
information on an application form available on request from the Board and on
the Board's web site:
1. Applicant's full
name, home address and telephone number, and primary e-mail address;
2. Number of previous pro bono
registration;
3. Name of each
state, U.S. territory, and province in which the applicant holds an active
medical license;
4. A statement
whether since issuance of the last pro bono registration:
a. Any disciplinary action has been taken
against the applicant, and
b. Any
unresolved complaints are currently pending against the applicant with any
state board; and
5. If
the document submitted under
R4-16-202(B)
was a limited form of work authorization issued by the federal government,
evidence that the applicant's presence in the U.S. continues to be authorized
under federal law.
