Physician
Complaint Form
To file a complaint against an
M.D. licensed in Arizona, download this printable
form which includes detailed instructions
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Physician
Assistant Complaint Form
To file a complaint against an
P.A. licensed in Arizona, download this printable
form which includes detailed instructions
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Public
Information Request Form
To request public information,
download this printable form which includes detailed
instructions
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License Verification Request Form
To request that a license verification (sometimes called a letter of good standing) be sent to another board or organization.
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Jury Duty Medical Excuse Form
Should a patient requests that they be excused from jury service for reasons related to mental or physical conditions.
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Data
Disk Order Form
To order a CD-ROM containing the
Physician and Physician Assistant Database, download
this printable form which includes detailed instructions
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Medical
Directory Order Form
To request a Physician and Physician
Assistant Directory via website download or via printable
request form
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Change
of Address Form
Licensees must notify the Board
in writing within thirty (30) days of any address
changes
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Legal
Name Change Form
To notify the Board of a legal
name change,
download these printable forms including payment instructions.
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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.
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Termination of Supervision
To terminate (end) supervision of a Physician Assistant, download this printable form to complete and return to the board.
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Application for an M.D. License
Has been moved to the Physician Center under New Arizona License. |