skip navigation
Arizona Medical Board
Agency Name
Official Website of the
Arizona Medical Board
The Board's mission is to protect public health and safety.


Credit Card Payment MD Duplicate License
To pay for a duplicate license by credit card
 
Physician Complaint Form
To file a complaint against an M.D. licensed in Arizona, download this printable form which includes detailed instructions
 
Physician Assistant Complaint Form
To file a complaint against an P.A. licensed in Arizona, download this printable form which includes detailed instructions
 
Public Information Request Form
To request public information, download this printable form which includes detailed instructions
 
License Renewal Form
Please allow 30 days for the processing of paper renewals.
 
License Verification Request Form
To request that a license verification (sometimes called a letter of good standing) be sent to another board or organization
 
Jury Duty Medical Excuse Form
Should a patient requests that they be excused from jury service for reasons related to mental or physical conditions
 
Data Disk Order Form
To order a CD-ROM containing the Physician and Physician Assistant Database, download this printable form which includes detailed instructions
 
Medical Directory Order Form
To request a Physician and Physician Assistant Directory via website download or via printable request form
 
Legal Name Change Form
To notify the Board of a legal name change, download this printable form.
 
Notice to Patients Form
A.R.S.§ 32-1401(26)(ff) requires that a physician notify a patient of any financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient
The statute requires that a physician use this Board prescribed form
 
A.D.O.T. Vision Examination Report, 32-4001
To document a patient’s visual impairment which may restrict driving
 
A.D.O.T. Driver Condition/Behavior Report, 96-0469
To report any patient condition or behavior which may restrict driving
 
Prescribing Modification Form
Supervising Physician Prescribing Modification Form
 
Evidence List- as referenced for the full MD license application
Evidence List form as referenced for the full MD license application
 
Evidence List- as referenced for miscellaneous license application types
Evidence List form as referenced for miscellaneous license application types
 
MD CME Audit Form
Please include with your renewal form, along with evidence of completed CME, only if you have been selected for random CME Audit.
 
Citizenship Statement
This form is to be completed by the applicant and is to be submitted with every type renewal application, permit or registration that is offered by the Arizona Medical Board, if the applicant has not previously established proof of citizenship with the Board.
 

The Arizona Medical Board uses Adobe Acrobat for the distribution of electronic versions of its documents. You must have the free Adobe Acrobat Reader installed on your computer to view these files.