Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 16 - ARIZONA MEDICAL BOARD › Article 2 - LICENSURE › Section R4-16-201.1 - Application for Renewal of License

Current through Register Vol. 30, No. 28, July 12, 2024
A. Under A.R.S. §
									32-1430(A),
				an individual licensed under A.R.S. Title 32, Chapter 13, shall renew the
				license every other year on or before the licensee's birthday.
B. To renew a license, a licensee shall
				submit the following information on an application form available on request
				from the Board and on the Board's web site:
1. The licensee's full name, license number,
				business and home addresses, primary e-mail address, and business and home
				telephone numbers;
2.
				Identification of changes to medical specialties and fields of
				practice;
3. A statement of
				whether, since the time of last license issuance, the licensee:
a. Has had an application for medical
				licensure denied or rejected by another state or province licensing board and
				if so, an explanation;
b. Has had
				any disciplinary or rehabilitative action taken against the licensee by another
				licensing board, including other health professions and if so, an
				explanation;
c. Has had any
				disciplinary action, restriction, or limitation taken against the licensee by
				any program or health care provider and if so, an explanation;
d. Has been subject to discipline resulting
				in a medical license being revoked, suspended, limited, cancelled during an
				investigation, restricted, or voluntarily surrendered, or resulting in
				probation or entry into a consent agreement or stipulation and if so, an
				explanation;
e. Has had hospital
				privileges revoked, denied, suspended, or restricted and if so, an explanation
				(do not report if the licensee's hospital privileges were suspended due to
				failure to complete hospital records and reinstated after no more than 90
				days);
f. Has been subjected to
				disciplinary action including censure, practice restriction, suspension,
				sanction, or removal from practice by an agency of the state or federal
				government and if so, an explanation;
g. Has had the authority to prescribe,
				dispense, or administer medications limited, restricted, modified, denied,
				surrendered, or revoked by a federal or state agency as a result of
				disciplinary or other adverse action and if so, an explanation;
h. Has been found guilty or entered into a
				plea of no contest to a felony, a misdemeanor involving moral turpitude, or an
				alcohol or drug-related offense in any state and if so, an explanation;
				and
i. Has failed the
				SPEX;
4. A statement of
				whether the licensee understands and complies with the medical records and
				recordkeeping requirements in A.R.S. §§
										32-3211
				and
				12-2297;
5. A statement of whether the licensee has
				completed at least 40 hours of CME as required under A.R.S. § 32-1434 and
				R4-16-102,
				including the hour of CME required under R4-16-102(A)(1);
6. A statement of whether the licensee
				requests that the license be inactivated or cancelled; and
7. A statement of whether the licensee
				completed a training unit prescribed by the Board regarding the requirements of
				A.R.S. Title 32, Chapter 13 and this Chapter.