Ariz. Admin. Code § R9-16-1003 - Renewal

A. At least 30 calendar days before the expiration date of a registered health care provider's registration, the registered health care provider shall submit to the Department:

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

a. The registered health care provider's name, home address, telephone number, and e-mail address;

b. The registered health care provider's registration number and date of expiration;

c. The name of the registered health care provider's professional liability insurance company, including whether the insurance policy covers claims occurring in Arizona;

d. The name, address, telephone number, e-mail address, and if applicable, a business name of the registered health care provider's statutory agent in Arizona;

e. Since the previous registration application, whether the applicant has:

i. Been convicted of a felony or a misdemeanor in this or another state,

ii. Had a license revoked or suspended in this or another state, or

iii. Had a disciplinary action taken against the applicant's license by any state or jurisdiction;

f. Whether the licensee is currently ineligible for licensure in any state because of a prior license revocation or suspension;

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

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

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

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

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

2. A report on the telehealth services provided by the registered health care provider in Arizona during the preceding year, including:

a. The beginning and ending dates for the report,

b. The number of clients the registered health care provider served in Arizona, and

c. The total number and type of encounters provided;

3. A copy of the applicant's professional liability insurance policy; and

4. If applicable, documentation about each conviction, revocation or suspension, or disciplinary action, or ineligible license taken specified in subsection (A)(1)(e).

B. A registered health care provider who does not submit the application in subsection (A) by the expiration date of the registration certificate shall apply for a new registration according to R9-16-1003.

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

D. The Department shall approve or deny an application for registration according to R9-16-1003.

Notes

Ariz. Admin. Code § R9-16-1003

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