Ariz. Admin. Code § R4-8-301 - Application for Auricular Acupuncture Certificate

To be certified as an auricular acupuncturist to provide auricular acupuncture services in a Board-approved alcoholism, substance abuse, or chemical dependency program, an applicant shall submit an application packet to the Board that includes:

1. An application, on a form provided by the Board, that provides the following information about the applicant:

a. Name;

b. Other names by which the applicant has been known;

c. Date of birth;

d. Social Security number;

e. Home, business, and e-mail addresses;

f. Home, business, and mobile telephone numbers;

g. A statement of whether the applicant has ever been permitted by law to practice auricular acupuncture in another state, territory, or district of the United States, or another country or subdivision of another country, and if so:

i. A list of the jurisdictions in which the applicant has been permitted by law to practice auricular acupuncture;

ii. The number of each license or certificate;

iii. The date each license or certificate was issued;

iv. The date each license or certificate expired or expires;

v. Limitations, if any, for each license or certificate;

vi. Current status of each license or certificate; and

vii. Whether each license or certificate was granted by endorsement, examination, or another means;

h. A statement of whether the applicant has ever had a licensing authority of another state, district, or territory of the United States, or another country or subdivision of another country, deny the applicant a license or certificate to practice auricular acupuncture, and if so, the name of the jurisdiction denying a license or certificate, date of the denial, and an explanation of the circumstances;

i. A statement of whether the applicant has ever had a licensing authority of another state, district, or territory of the United States, or another country or subdivision of another country, revoke, suspend, limit, restrict, or take any other action regarding the applicant's license or certificate to practice auricular acupuncture, and if so, the name of the jurisdiction taking the action, the action taken, date of the action, and an explanation of the circumstances;

j. A statement of whether the applicant has ever been convicted of a crime, including driving under the influence of drugs or alcohol, other than a minor traffic offense, and if so, the name of the jurisdiction in which convicted, the nature of the crime, date of the conviction, and current status;

k. A statement of whether the applicant has ever had a claim for malpractice or a lawsuit filed against the applicant alleging professional malpractice or negligence in the practice of auricular acupuncture, and if so, the claim or case number, date of the claim or lawsuit, the matters alleged, and whether the claim or lawsuit is still pending or the manner in which it was resolved;

l. A statement of whether the applicant has any condition that may impair the applicant's ability to practice auricular acupuncture safely and skillfully, and if so, the nature of the condition and any accommodations necessary;

m. A statement of whether the applicant has ever resigned, voluntarily or involuntarily, from a health-care facility while under investigation, and if so, the name of the health-care facility, the date of the resignation, and an explanation of the circumstances; and

n. A statement of whether the applicant has ever had a health-care facility terminate, restrict, or take any other action regarding the applicant's employment, professional training, or privileges, and if so, the name of the health-care facility, the date of the action, and an explanation of the circumstances;

2. An official record or document that relates to the applicant's explanation of an item under subsections (1)(h) through (1)(n);

3. The application and initial certification fees prescribed by the Board under R4-8-106(A)(5) and (A)(6);

4. Documentation of successfully completing a Board-approved:

a. Training program in auricular acupuncture for the treatment of alcoholism, substance abuse, or chemical dependency. A copy of the certificate of completion showing the name, date, and location of the course is acceptable documentation; and

b. Clean needle technique course. A copy of the certificate of completion showing the name, date, and location of the course is acceptable documentation;

5. The name, license number, and telephone number of the Arizona licensed acupuncturist who will supervise the applicant if the applicant is certified;

6. A 2" X 2" photograph, taken within the last year, that shows the front of the applicant's face and that the applicant signs on the back or the white frame around the photograph;

7. A completed Arizona Statement of Citizenship and Alien Status for State Public Benefits, which is a form available from the Board; and

8. The applicant's dated and notarized signature affirming that the information provided in the application, including any accompanying documents submitted by or on behalf of the applicant, are true and complete.

Notes

Ariz. Admin. Code § R4-8-301

New Section adopted by final rulemaking at 6 A.A.R. 2534, effective June 12, 2000 (Supp. 00-2). Section R4-8-301 recodified to R4-8-401 at 13 A.A.R. 482, effective January 24, 2007 (Supp. 07-1). New R4-8-301 renumbered from R4-8-201 and amended by final rulemaking at 14 A.A.R. 690, effective April 5, 2008 (Supp. 08-1).