Ariz. Admin. Code § R9-16-1002 - Initial Application

A. An applicant for initial registration to provide telehealth services in Arizona shall submit to the Department an application that contains:

1. The following information in a Department-provided format:

a. The applicant's name, home address, telephone number, and e-mail address;

b. The applicant's Social Security number, as required under A.R.S. §§ 25-320 and 25-502;

c. The type of telehealth registration the applicant is requesting;

d. Information about the license held by the applicant, including the:

i. State or jurisdiction that issued the license,

ii. The license number, and

iii. The license date of expiration;

e. The name of the applicant's professional liability insurance company, including whether the insurance policy covers claims occurring in Arizona;

f. The name, address, telephone number, e-mail address, and, if applicable, business name of the applicant's statutory agent in Arizona;

g. Whether the applicant has ever been convicted of a felony or a misdemeanor in this or another state or jurisdiction and, if so:

i. The date of the conviction,

ii. The state or jurisdiction of the conviction,

iii. An explanation of the crime of which the applicant was convicted, and

iv. The disposition of the case;

h. Whether the applicant has had a license revoked or suspended;

i. Whether the applicant has had a disciplinary action taken against the applicant's license by any state or jurisdiction and, if so:

i. The date of the disciplinary action,

ii. The state or jurisdiction of the disciplinary action, and

iii. An explanation of the disciplinary action;

j. Whether the applicant is currently ineligible for licensure in any state because of a revocation or suspension and, if so, documentation that includes:

i. The date of ineligibility for licensure,

ii. The state or jurisdiction of the ineligibility for licensure, and

iii. An explanation of the ineligibility for licensure;

k. Whether the applicant agrees to allow the Department to submit supplemental requests for information under R9-16-1006 ;

l. An attestation that the applicant authorizes the Department to verify all information provided in the application;

m. An attestation that the applicant agrees to comply with the requirements in this Article and A.R.S. § 36-3606;

n. An attestation that the information submitted as part of the application is true and accurate; and

o. The applicant's signature and date of signature;

2. A copy of the license for each jurisdiction where the applicant holds or held a license;

3. A copy of the applicant's professional liability insurance policy, including:

a. The name of the insurance provider,

b. Policy number,

c. Coverage for telehealth services, and

d. Policy limits and amounts;

4. Documentation that complies with A.R.S. § 41-1080;

5. If applicable, documentation about each conviction of a felony or misdemeanor supporting the information specified in subsection (A)(1)(g);

6. If applicable, documentation about each disciplinary action specified in subsection (A)(1)(i), including any legal order or settlement agreement related to the action taken;

7. If applicable, documentation about each revocation or suspension specified in subsection (A)(1)(j), including any legal order or settlement agreement; and

8. A nonrefundable fee of $100.

B. The Department shall review the application and required documentation for initial registration as a registered health care provider according to R9-16-1006 and Table 10.1.

C. The Department shall approve or deny an application for registration according to R9-16-1002.

Notes

Ariz. Admin. Code § R9-16-1002

New Section made by final rulemaking at 30 A.A.R. 695, effective 5/13/2024.