Section R4-16-201. Application for Licensure by Examination or Endorsement

A.      For purposes of this Article, unless otherwise specified:

1.        “ABMS” means American Board of Medical Specialties.

2.        “ECFMG” means Educational Commission for Foreign Medical Graduates.

3.        “FCVS” means Federation Credentials Verification Ser- vice.

4.        “FLEX” means Federation Licensing Examination.

5.        “LMCC” means Licentiate of the Medical Council of Canada.

6.        “NBME” means National Board of Medical Examiners.

7.        “Primary  source”  means  the  original  source  or  an approved agent of the original source of a specific cre-

dential that can verify the accuracy of a qualification reported by an applicant.

8.        “SPEX” means Special Purposes Examination.

9.        “USMLE” means United States Medical Licensing Examination.

B.       An applicant for licensure to practice medicine by Step 3 of the USMLE or endorsement shall submit the following infor- mation on an application form available on request from the Board and on the Board’s web site:

1.        Applicant’s full name, Social Security number, business and home addresses, primary e-mail address, business and home telephone numbers, and date and place of birth;

2.        Name of the school of medicine from which the applicant graduated and date of graduation;

3.        A complete list of the applicant’s internship, residency, and fellowship training;

4.        List of all licensing examinations taken;

5.        Names of the states, U.S. territories, or provinces in which the applicant has applied for or been granted a license or registration to practice medicine, including license number, date issued, and current status of the license;

6.        A statement of whether the applicant:

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 ever had any disciplinary or rehabilitative action taken against the applicant by another licensing board, including other health professions, and if so, an explanation;

c.         Has had any disciplinary actions, restrictions, or lim- itations taken against the applicant while participat- ing in any type of training program or by any health care provider, and if so, an explanation;

d.        Has been found in violation of a statute, rule, or reg- ulation of  any domestic or foreign governmental agency, and if so, an explanation;

e.         Is currently under investigation by any medical board or peer review body, and if so, an explanation;

f.         Has been subject to discipline resulting in a medical license being revoked, suspended, limited, cancelled during investigation, restricted, or voluntarily sur- rendered, or resulting in probation or entry into a consent agreement or stipulation and if so, an expla- nation;

g.        Has had hospital privileges revoked, denied, sus- pended, or restricted, and if so, an explanation;

h.        Has been named as a defendant in a malpractice matter currently pending or that resulted in a settle- ment or judgment against the applicant, and if so, an explanation;

i.         Has been subjected to any regulatory disciplinary action, including censure, practice restriction, sus- pension, sanction, or removal from practice, imposed by any agency of the federal or state gov- ernment, and if so, an explanation;

j.         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;

k.        Has been found guilty or entered into a plea of no contest to a felony, a misdemeanor involving moral turpitude in any state, and if so, an explanation;

7.        Whether the applicant is currently certified by any of the American Board of Medical Specialties;

8.        The applicant’s intended specialty;

9.        Consistent with the Board’s authority at A.R.S. § 32- 1422(B), other information the Board may deem neces- sary to evaluate the applicant fully;

10.     Whether the applicant completed a training unit pre- scribed  by  the  Board  regarding   the  requirements  of

A.R.S. Title 32, Chapter 13 and this Chapter;

11.     In addition to the answers provided under subsections (B)(1) through (B)(10), the applicant shall answer the fol- lowing confidential question:

a.         Whether the applicant has received treatment within the last five years for use of alcohol or a controlled substance, prescription-only drug, or dangerous drug or narcotic or a physical, mental, emotional, or ner- vous disorder or condition that currently affects the applicant’s ability to exercise the judgment and skills of a medical professional;

b.        If the answer to subsection (B)(11)(a) is yes:

i.         A detailed description of the use, disorder, or condition; and

ii.        An explanation of whether the use, disorder, or condition is reduced or ameliorated because the applicant receives ongoing treatment and if so, the name and contact information for all current treatment providers and for all monitoring or support programs in which the applicant is cur- rently participating; and

c.         A copy of any public or confidential agreement or order relating to the use, disorder, or condition, issued by a licensing agency or health care institu- tion within the last five years, if applicable; and

12.     A notarized statement, signed by the applicant, verifying the truthfulness of the information provided, and that the applicant has not engaged in any acts prohibited by Ari- zona law or Board rules, and authorizing release of any required records or documents to complete application review.

C.      In addition to the application form required under subsection (B), an applicant for licensure to practice medicine by Step 3 of the USMLE or endorsement shall submit the following:

1.        A copy of the applicant’s birth certificate or passport with a notarized certificate of identification, which is a form available on request from the Board and on the Board’s web site;

2.        Evidence of legal name change if the applicant’s legal name is different from that shown on the document sub- mitted under subsection (C)(1);

3.        Documentation listed under A.R.S. § 41-1080(A) show- ing that the applicant’s presence in the U.S. is authorized under federal law;

4.        Complete list of all hospital affiliations and medical employment for the five years before the date of applica- tion;

5.        Verification of any medical malpractice matter currently pending or resulting in a settlement or judgment against the applicant, including a copy of the complaint and either the agreed terms of settlement or the judgment and a narrative statement specifying the nature of the occur- rence resulting in the medical malpractice action.  An applicant who is unable to obtain a document required under this subsection may apply under subsection (E) a waiver of the requirement;

6.        A full set of fingerprints and the processing charge speci- fied in R4-16-205;

7.        A paper or digital headshot photograph of the applicant taken no more than 60 days before the date of application; and

8.        The fee authorized under A.R.S. § 32-1436 and specified in R4-16-205.

D.      In addition to the requirements of subsections (B) and (C), an applicant for licensure to practice medicine by Step 3 of the USMLE or endorsement shall have the following submitted to the Board, electronically or in hard copy, by the primary source, ECFMG, Veridoc, or FCVS:

1.        Official transcript or other authentication of graduation from a school of medicine;

2.        Verification of completion of postgraduate training;

3.        Verification of ECFMG certification if the applicant grad- uated from an unapproved school of medicine;

4.        Examination and Board history report scores for USMLE, FLEX, NBME, and SPEX;

5.        Verification of LMCC exam score or state written exam score;

6.        Verification of licensure from every state in which the applicant has ever held a medical license;

7.        Verification of all hospital affiliations during the five years before the date of application. Under A.R.S. § 32- 1422(A)(11)(b), this verification is required to be on the hospital’s official letterhead or the electronic equivalent; and

8.        Verification of all medical employment during the five years before the date of application. Under A.R.S. § 32- 1422(A)(11)(b), this verification may be submitted by the employer.

E.       As provided under A.R.S. § 32-1422(F), the Board may waive a documentation requirement specified under subsections (C)(5) and (D).

1.        To obtain a waiver under this subsection, an applicant shall submit a written request that includes the following information:

a.         Applicant’s name;

b.        Date of request;

c.         Document required under subsection (C)(5) or (D) for which waiver is requested;

d.        Detailed description of efforts made by the applicant to provide the document as required under subsec- tion (C)(5) or (D);

e.         Reason the applicant’s inability to provide the docu- ment as required under subsection (C)(5) or (D) is due to no fault of the applicant; and

f.         If applicable, documents that support the request for waiver.

2.        The Board shall consider the request for waiver at its next regularly scheduled meeting.

3.        In determining whether to grant the request for waiver, the Board shall consider whether the applicant:

a.         Made appropriate and sufficient effort to satisfy the requirement under subsection (C)(5) or (D); and

b.        Demonstrated that compliance with the requirement under subsection (C)(5) or (D) is not possible because:

i.         The entity responsible for issuing the required document no longer exists;

ii.        The original of the required document was destroyed by accident or natural disaster;

iii.      The entity responsible for issuing the required document is unable to provide verification because of armed conflict or political strife; or

iv.       Another valid reason beyond the applicant’s control prevents compliance with the require- ment under subsection (C)(5) or (D).

4.        In determining whether to grant the request for waiver, the Board shall:

a.         Consider whether it is  possible for the Board to obtain the required document from other source; and

b.        Request the applicant to obtain and provide addi- tional information the Board believes will facilitate the Board’s decision.

5.        If the Board determines the applicant is unable to comply with a requirement under subsection (C)(5) or (D) in spite of the applicant’s best effort and for a reason beyond the applicant’s control, the Board may grant the request for waiver and include the decision in the Board’s official record for the applicant.

6.        The Board shall provide the applicant with written notice of its decision regarding the request for waiver. The Board’s decision is not subject to review or appeal.

F.       As provided under A.R.S. § 32-1426(B), the Board may require an applicant for licensure by endorsement who passed an examination specified in A.R.S. § 32-1426(A) more than ten years before the date of application to provide evidence the applicant is able to engage safely in the practice of medicine.

1.        If an applicant is board certified by one of the specialties recognized by the ABMS, the Board shall find that the applicant is able to engage safely in the practice of medi- cine.

2.        If an applicant is not board certified by one of the special- ties recognized by the ABMS, the Board may consider one or more of the following to determine whether the applicant is able to engage safely in the practice of medi- cine:

a.         The applicant’s records,

b.        The applicant’s practice history,

c.         The applicant’s score on the SPEX, and

d.        A physical or psychological assessment of the appli- cant.

Historical Note

Adopted effective September 22, 1995 (Supp. 95-3). Amended by final rulemaking at 8 A.A.R. 2319, effective May 9, 2002 (Supp. 02-2). Former Section R4-16-201 recodified to R4-16-301; New Section R4-16-201 recodi- fied from R4-16-106 at 11 A.A.R. 1283, effective March 25, 2005 (Supp. 05-1). Amended by exempt rulemaking

at 20 A.A.R. 1995, effective July 11, 2014 (Supp. 14-3). Amended by final exempt rulemaking at 21 A.A.R. 2678, effective October 15, 2015 (Supp. 15-4).