Ariz. Admin. Code § R4-17-203 - Regular License Application

A. An applicant for a regular license shall submit a completed application to the Board that includes:

1. The applicant's:

a. First, last, and middle name;

b. Every other name used by the applicant;

c. Social Security number;

d. Office, mailing, e-mail, and home addresses;

e. Office, mobile, and home telephone numbers; and

f. Birth date and state or country of birth;

2. The name and address of the approved physician assistant program completed by the applicant and the date of completion;

3. The name of each state or province in which the applicant has ever been certified, registered, or licensed as a physician assistant, including the certificate, registration, or license number, and current status;

4. Whether the applicant has practiced as a physician assistant for 10 continuous years before the date the application was submitted to the Board or since graduation from a physician assistant program and if not, an explanation;

5. A questionnaire that includes answers to the following:

a. Whether the applicant has had an application for a certificate, registration, or license refused or denied by any licensing authority, and if so, an explanation;

b. Whether the applicant has had the privilege of taking an examination for a professional license refused or denied by any entity, and if so, an explanation;

c. Whether the applicant has ever resigned or been requested to resign, been suspended or expelled from, been placed on probation, or been fined while enrolled in an approved physician assistant program or a postsecondary educational program, and if so, an explanation;

d. Whether, while attending an approved physician assistant program, the applicant has ever had any action taken against the applicant by the approved program, resigned, or been asked to leave the approved program for any amount of time, and if so, an explanation;

e. Whether the applicant has ever surrendered a health professional license, and if so, an explanation;

f. Whether the applicant has ever had a health professional license suspended or revoked, or whether any other disciplinary action has ever been taken against a health professional license held by the licensee, and if so, an explanation;

g. Whether the applicant is currently under investigation by any health profession regulatory authority, health care association, licensed health care institution, or there are any pending complaints or disciplinary actions against the applicant, and if so, an explanation;

h. Whether the applicant has ever had any action taken against the applicant's privileges, including termination, resignation, or withdrawal by a health care institution or health profession regulatory authority, and if so, an explanation;

i. Whether the applicant has ever had a federal or state regulatory authority take any action against the applicant's authority to prescribe, dispense, or administer controlled substances including revocation, suspension, or denial, or whether the applicant ever surrendered the authority in lieu of any of these actions, and if so, an explanation;

j. Whether the applicant has ever been charged with, convicted of, pleaded guilty to, or entered into a plea of no contest to a felony or misdemeanor involving moral turpitude or has been pardoned or had a record expunged or vacated, and if so, an explanation;

k. Whether the applicant has ever been charged with or convicted of a violation of any federal or state drug statute, rule, or regulation, regardless of whether a sentence was or was not imposed, and if so, an explanation;

l. Whether the applicant has been named as a defendant in a malpractice matter currently pending or that resulted in a judgment or settlement entered against the applicant, and if so, an explanation;

m. Whether the applicant has ever been court-martialed or discharged other than honorably from any component of the uniformed services of the United States, and if so, an explanation;

n. Whether the applicant has ever been involuntarily terminated from a health professional position, resigned, or been asked to leave the health care position, and if so, an explanation;

o. Whether the applicant has ever been convicted of insurance fraud or received a sanction, including limitation, suspension, or removal from practice, imposed by any state or the federal government, and if so, an explanation; and

p. Whether the applicant, within the three years before the date of the application, has completed 45 hours in pharmacology or clinical management of drug therapy or is certified by a national commission on the certification of physician assistants or its successor;

6. A confidential questionnaire that includes answers to the following:

a. Whether the applicant currently has a medical condition that impairs the applicant's judgment or ability to practice medicine in a competent, ethical, and professional manner;

b. If the answer to subsection (A)(6)(a) is yes:

i. Provide an explanation of the medical condition; and

ii. If currently practicing under a monitoring agreement with a licensing board in another state, attach a copy of the monitoring agreement to the application; and

c. A copy of any public or confidential agreement or order relating to the use, disorder, or condition, issued by a licensing agency or health care institution within the last five years, if applicable;

7. Consistent with the Board's statutory authority, other information the Board may deem necessary to evaluate the applicant fully; and

8. A sworn statement that complies with A.R.S. § 32-2522(C).

B. In addition to the requirements in subsection (A), an applicant shall submit the following to the Board:

1. Documentation of citizenship or alien status that conforms to A.R.S. § 41-1080;

2. Documentation of a legal name change if the applicant's legal name is different from that shown on the document submitted in accordance with subsection (B)(1);

3. A form provided by the Board and completed by the applicant that lists all current or past employment with health professionals, health professions educational institutions, or health care institutions within five years before the date of application or since graduation from a physician assistant program, if less than five years, including each health professional's, health professions educational institution's, or health care institution's name, address, and dates of employment;

4. Verification of any medical malpractice matter currently pending or resulting in a settlement or judgment against the applicant, including a copy of the complaint and either the agreed terms of settlement or the judgment and a narrative statement specifying the nature of the occurrence resulting in the medical malpractice action. An applicant who is unable to obtain a document required under this subsection may submit a written request for a waiver of the requirement. The applicant shall include the following information in a request for waiver:

a. The document for which waiver is requested;

b. Detailed description of efforts made by the applicant to provide the required document; and

c. Reason the applicant's inability to provide the required document is due to no fault of the applicant; and

5. The fee required in R4-17-204.

C. In addition to the requirements in subsections (A) and (B), an applicant shall have the following directly submitted to the Board:

1. A copy of the applicant's certificate of successful completion of the PANCE or PANRE and the applicant's examination score provided by the NCCPA;

2. An approved program form provided by the Board, completed and signed by the director or administrator of the approved program that granted the applicant a physician assistant degree, that includes the:

a. Applicant's full name,

b. Type of degree earned by the applicant,

c. Name of the physician assistant program completed by the applicant,

d. Starting and ending dates, and

e. Date the applicant's degree was granted.

D. The Board's issuance of a regular license to an applicant certifies the applicant to issue, dispense, or administer schedule II or schedule III controlled substances, subject to the limits and requirements specified in A.R.S. § 32-2532. Additionally, beginning October 1, 2018, a physician assistant previously certified by the Board for 30-day prescription privileges for schedule II or schedule III controlled substances is certified for 90-day prescription privileges for schedule II or schedule III controlled substances that are not opioids or benzodiazepine.

Notes

Ariz. Admin. Code § R4-17-203

Adopted effective July 8, 1986 (Supp. 86-4). Section repealed; new Section adopted effective April 22, 1998 (Supp. 98-2). Amended by final rulemaking at 18 A.A.R. 2123, effective October 7, 2012 (Supp. 12-3). Amended by final rulemaking at 22 A.A.R. 3700, effective 2/6/2017. Amended by final rulemaking at 25 A.A.R. 401, effective 4/6/2019. Amended by final rulemaking at 28 A.A.R. 1757, effective 9/4/2022.