Ariz. Admin. Code § R4-38-108 - Application for Licensure

A. To apply for licensure, an applicant shall submit the following directly to the Board:

1. An application form that contains the following information about the applicant:

a. Name as the applicant wants the name to appear on a license;

b. Social Security number, as required under A.R.S. §§ 25-320(P) and 25-502(K);

c. Date and place of birth;

d. Personal identifying characteristics including gender, weight, height, eye and hair colors, and any identifying marks;

e. Business name and address;

f. Residential address;

g. Business telephone and fax numbers;

h. E-mail address;

i. Date on which the applicant expects to take the written examination required under A.R.S. § 32-2913;

j. Name of the approved medical school from which the applicant obtained an allopathic or osteopathic medical degree and the date of the degree;

k. Name of the hospital program at which the applicant served as an intern and the years of the internship;

l. Names and addresses of three physicians who will send the Board letters of recommendation for the applicant;

m. List of the states or other jurisdictions in which the applicant is or ever has been licensed to practice medicine;

n. List of specialty colleges of which the applicant is a member;

o. List of specialty boards by which the applicant is certified;

p. List of the places where the applicant has practiced medicine and the dates of practice;

q. Statement indicating whether the applicant:

i. Has, within the last 10 years, had a medical malpractice judgment entered against an applicant or settled a malpractice claim against the applicant;

ii. Has ever been convicted of or pled guilty or nolo contendere to a criminal charge in an adult court of record;

iii. Has been charged with a crime that is pending adjudication in an adult court of record;

iv. Has had a state or other jurisdiction refuse or deny the applicant a license to practice medicine or has allowed the applicant to withdraw a license application instead of being refused or denied a license to practice medicine;

v. Has had a state or other jurisdiction take disciplinary action against the applicant's license to practice medicine including placing the license on probation, suspending the license, limiting or restricting the license, revoking the license, or accepting surrender of the license;

vi. Has had a state or other jurisdiction, including a federal agency, suspend, limit, restrict, revoke, deny, or accept surrender in lieu of action of the applicant's registration to possess, dispense, or prescribe controlled substances;

vii. Has or had, within the last 10 years, a mental illness or psychological condition that impaired the applicant's ability to practice medicine or function as a medical student;

viii. Is now or has been within the last 10 years dependent upon alcohol or drugs; and

ix. Has had a specialty board or college suspend, revoke, or deny certification to the applicant.

r. Notarized signature and attestation that the information provided is true, correct, and complete;

2. A summary listing the course title, sponsor, dates attended, and credit hours and evidence of completing the 300 hours of postgraduate coursework required under R4-38-104 or the preceptorship required under R4-38-105;

3. If the answer to any item in subsections (A)(1)(q)(i) through (ix) is yes, detailed information regarding the nature, date, and location of the incident, or the nature of the condition, and the identity of the agency, court, or organization involved, action taken, and current status;

4. An Arizona Statement of Citizenship and documentary evidence of U.S. citizenship or qualified alien status;

5. A list of the homeopathic modalities the applicant intends to make available under the applicant's supervision if the applicant is licensed;

6. If the applicant intends to use an experimental form of diagnosis or treatment in the applicant's homeopathic medical practice, a copy of the written informed consent materials that a patient will sign before examination or treatment;

7. Two photographs of the applicant's face taken within the last 60 days;

8. A copy of the membership card provided by a specialty college of which the applicant is a member;

9. A copy of the certification card provided by a specialty board by which the applicant is certified;

10. A completed and signed form authorizing individuals, organizations, previous employers, and schools to release to the Board information regarding the applicant;

11. A current curriculum vitae that includes all professional activity from medical school to the present; and

12. The license application fee specified in R4-38-106.

B. An applicant for licensure shall ensure that the following information is submitted directly to the Board:

1. Verification of graduation provided by the allopathic or osteopathic medical college from which the applicant graduated;

2. Letters of recommendation, on professional letterhead and notarized, from three licensed physicians; and

3. Verification of licensure from every jurisdiction in which the applicant is or ever has been licensed to practice medicine.

Notes

Ariz. Admin. Code § R4-38-108

Adopted effective June 13, 1988 (Supp. 88-2). Amended by final rulemaking at 11 A.A.R. 2008, effective July 2, 2005 (Supp. 05-2). Former R4-38-108 renumbered to R4-38-110; new Section made by final rulemaking at 17 A.A.R. 1980, effective November 12, 2011 (Supp. 11-3).