Section R4-16-202. Application and Reapplication for Pro Bono Reg- istration

A.      An applicant for a pro bono registration to practice medicine for a maximum of 60 days in a calendar year in Arizona shall submit the following information on an application form avail- able 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, and busi- ness and home telephone numbers;

2.        List of all states, U.S. territories, and provinces in which the applicant is or has been licensed to practice medicine;

3.        A statement verifying that the applicant:

a.         Agrees to render all medical services without accepting a fee or salary; or

b.        Agrees to perform only initial or follow-up examina- tions at no cost to the patient or the patient’s family through a charitable organization,

B.       In addition to the application form required under subsection (A), an applicant for a pro bono registration to practice medi- cine shall submit documentation listed under A.R.S. § 41- 1080(A) showing that the applicant’s presence in the U.S. is authorized under federal law.

C.      An applicant may make application for a pro bono registration annually. A previously registered applicant may apply for a pro bono registration by submitting the following information on an application form available on request from the Board and on the Board’s web site:

1.        Applicant’s full name, home address and telephone num- ber, and primary e-mail address;

2.        Number of previous pro bono registration;

3.        Name of each state, U.S. territory, and province in which the applicant holds an active medical license;

4.        A statement whether since issuance of the last pro bono registration:

a.         Any disciplinary action has been taken against the applicant, and

b.        Any unresolved complaints are currently pending against the applicant with any state board; and

5.        If the document submitted under R4-16-202(B) was a limited form of work authorization issued by the federal government, evidence that the applicant’s presence in the

U.S. continues to be authorized under federal law.

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 R4-16-202 recodified to R4-16-302; New Section R4-16-202 recodi- fied from R4-16-107 at 11 A.A.R. 1283, effective March 25, 2005 (Supp. 05-1). Amended by final exempt

rulemaking at 21 A.A.R. 2678, effective October 15,

2015 (Supp. 15-4).