Section R4-17-203. Regular License Application

A.      An applicant for a regular license shall submit a completed application to the Board that includes:

1.        The applicant’s:

a.        First, last, and middle name;

b.        Every other name used by the applicant;

c.        Social Security number;

d.        Practice address and telephone number;

e.        Mailing address, if different from the practice address;

f.         Home address and telephone number; and

g.        Birth date and city or country of birth;

2.        The name and address of the approved program com- pleted by the applicant and the date of completion;

3.        The name of each state or province in which the applicant has ever been certified, registered, or licensed as a physi- cian assistant, including the certificate, registration, or license number, and current status;

4.        Whether the applicant has practiced as a physician assis- tant since graduation from a physician assistant program or for 10 continuous years before the date the application was submitted to the Board and if not, an explanation;

5.        A questionnaire that includes answers to the following:

a.        Whether the applicant has had an application for a certificate, registration, or license refused or denied by any licensing authority, and if so, an explanation;

b.        Whether the applicant has had the privilege of taking an examination for a professional license refused or denied by any entity, and if so, an explanation;

c.        Whether the applicant has ever resigned or been requested to resign, been suspended or expelled from, been placed on probation, or been fined while enrolled in an approved program in a medical school or a postsecondary educational program, and if so, an explanation;

d.        Whether, while attending an approved program, the applicant has ever had any action taken against the applicant by an approved program, resigned, or been asked to leave the approved program for any amount of time, and if so, an explanation;

e.        Whether the applicant has ever surrendered a health professional license, and if so, an explanation;

f.         Whether the applicant has ever had a health profes- sional license suspended or revoked, or whether any other disciplinary action has ever been taken against a health professional license held by the licensee, and if so, an explanation;

g.        Whether the applicant is currently under investiga- tion by any health profession regulatory authority, healthcare association, licensed health care institu- tion, or there are any pending complaints or disci- plinary actions against the applicant, and if so, an explanation;

h.        Whether the applicant has ever had any action taken against the applicant’s privileges, including termina- tion, resignation, or withdrawal by a health care institution or health profession regulatory authority, and if so, an explanation;

i.         Whether the applicant has ever had a federal or state authority take any action against the applicant’s authority to prescribe, dispense, or administer con- trolled substances including revocation, suspension, denial, or whether the applicant ever surrendered such authority in lieu of any of these actions, and if so, an explanation;

j.         Whether the applicant has ever been charged with, convicted of, pleaded guilty to, or entered into a plea of no contest to a felony or misdemeanor involving moral turpitude or has been pardoned or had a record expunged or vacated, and if so, an explanation;

k.        Whether the applicant has ever been charged with or convicted of a violation of any federal or state drug statute, rule, or regulation, regardless of whether a sentence was or was not imposed, and if so, an explanation;

l.         Whether the applicant, within the last 10 years from the date of the application, has had a judgment or a settlement entered against the applicant in a medical malpractice suit, and if so, an explanation;

m.      Whether the applicant has ever been court-martialed or discharged other than honorably from any branch of military service, and if so, an explanation;

n.        Whether the applicant has ever been involuntarily terminated from a health professional position, resigned, or been asked to leave the health care posi- tion, and if so, an explanation;

o.        Whether the applicant has ever been convicted of insurance fraud or received a sanction, including limitation, suspension, or removal from practice, imposed by any state or the federal government, and if so, an explanation; and

p.        Whether the applicant, within the last three years before the date of the application, has completed 45 hours in pharmacology or clinical management of drug therapy or is certified by a national commission on the certification of physician assistants or its suc- cessor;

6.        A confidential questionnaire that includes answers to the following:

a.        Whether the applicant, within the last five years before the date of the application, has been diag- nosed with or treated for bi-polar disorder, schizo- phrenia, paranoia, or any other psychotic disorder, and if so, an explanation;

b.        Whether the applicant is currently being treated by a health professional or, within five years from the date of the application, has been treated by a health professional for substance use disorder or partici-

pated in a rehabilitation program for a substance use disorder, and if so, an explanation that includes:

i.         The name of each health professional or health care institution that addressed the substance use disorder and a discharge summary that includes progress made by the applicant; or

ii.        A copy of the confidential agreement or order issued by a health professional or health care institution, if applicable; and

c.        Whether the applicant currently has any disease or condition, including a behavioral health illness or condition, substance use disorder, physical disease or condition that interferes with the applicant’s abil- ity to perform health care tasks authorized by A.R.S.

§ 32-2531 and if so, an explanation;

7.        Consistent with the Board’s statutory authority, such other information as the Board may require to fully evalu- ate the applicant; and

8.        A sworn statement that complies with A.R.S. § 32- 2522(C).

B.       In addition to the requirements in subsection (A), an applicant shall submit the following to the Board:

1.        Documentation of citizenship or alien status that con- forms to A.R.S. § 41-1080;

2.        Documentation of a legal name change if the applicant’s legal name is different from that shown on the document submitted in accordance with subsection (B)(1);

3.        A form provided by the Board and completed by the applicant that lists all current or past employment with health professionals or health care institutions within five years before the date of application or since graduation from a physician assistant program, if less than five years, including each health professional’s or health care institu- tion’s name, address, and dates of employment;

4.        If the applicant has more than one malpractice settlement or judgment against the applicant within 10 years from the date of the application, a form provided by the Board for each malpractice settlement or judgment against the applicant that includes:

a.        The applicant’s name;

b.        A description of the event that led to the malpractice settlement or judgment including:

i.         The patient’s name, age, and sex;

ii.        The date of occurrence;

iii.      Location of occurrence; and

iv.      A detailed narrative of the event;

c.        The amount of the settlement or judgment;

d.        The date the settlement was entered into or judgment was made;

e.        The amount of the settlement or judgment attributed to the applicant; and

f.         Whether any state medical board has investigated the matter; and

5.        The fee required in R4-17-204.

C.      In addition to the requirements in subsections (A) and (B), an applicant shall have the following directly submitted to the Board:

1.        A copy of the applicant’s certificate of successful com- pletion of the NCCPA examination and the applicant’s examination score provided by the NCCPA;

2.        An approved program form provided by the Board, com- pleted and signed by the director or administrator of the approved program that granted the applicant a physician assistant degree, that includes the:

a.        Applicant’s full name,

b.        Type of degree earned by the applicant,

c.        Name of the physician assistant program completed by the applicant,

d.        Starting and ending dates, and

e.        Date the applicant’s degree was granted.

D.      When the Board issues a regular license to an applicant, the Board is also approving the applicant to issue prescriptions or dispense or issue schedule II or schedule III controlled sub- stances.

Historical Note

Adopted effective July 8, 1986 (Supp. 86-4). Section repealed; new Section adopted effective April 22, 1998 (Supp. 98-2). Amended by final rulemaking at 18 A.A.R.

2123, effective October 7, 2012 (Supp. 12-3).