Telehealth

Application

Type of Application

Psychologist

Behavior Anaylst

Applicant Information

First Name

Last Name

Middle Name

Address

City

State

Zip

Work Phone

#

Personal Phone

#

Email

@

Confirm email

@

U.S. jurisdictions in which you have ever held a license, and indicate the license number

Upload Documents

Upload evidence of possessing professional liability insurance coverage that includes coverage for telehealth services provided in Arizona

One file only.
100 MB limit.
Allowed types: pdf.

Upload evidence of having secured a duly appointed statutory agent for service of process in Arizona, signed and dated by the agent

One file only.
100 MB limit.
Allowed types: pdf.

Upload a copy of your National Practitioner Data Bank self-query generated within 30 days prior to submission of this application

One file only.
100 MB limit.
Allowed types: pdf.

Upload a signed statement that you have read the Arizona Revised Statutes and the Arizona Administrative Code sections that govern your practice in this state

One file only.
100 MB limit.
Allowed types: pdf.

Upload a signed statement affirming you will annually update your registration with the relevant Board and will submit to the Board a report with the number of patients served in Arizona and the total number and type of encounters in this state for the preceding year

One file only.
100 MB limit.
Allowed types: pdf.

Agreement

I agree to act in full compliance with all applicable laws and rules of this state, including scope of practice, laws and rules governing prescribing, dispensing and administering prescription drugs and devices, telehealth requirements and the best practice guidelines adopted by the telehealth advisory committee on telehealth best practices.

agree to follows this state's standards of care for the particular licensed health profession for which I am registering.

I affirm I will not open an office in Arizona, except as part of a multistate provider group that includes at least one health care provider who is licensed in this state through the applicable health care provider regulatory board or agency.

I understand that failure to comply with the applicable laws and rules of this state is subject to investigation and both nondisciplinary and disciplinary action by the applicable health care provider regulatory board or agency in this state. For the purposes of disciplinary action by the applicable health care provider regulatory board or agency in this state, all statutory authority regarding investigating, rehabilitating and educating health care providers may be used. I further understand that if I fail to comply with the applicable laws and rules of this state, the applicable health care provider regulatory board or agency in this state may revoke or prohibit my privileges in this state, report the action to the national practitioner database and refer the matter to the licensing authority in the state or states where I possess a professional license. In any matter or proceeding arising from such a referral, the applicable health care provider regulatory board or agency in this state may share any related disciplinary and investigative information in its possession with another state licensing board.

I understand that the venue for any civil or criminal action arising from a violation of this section is the patient's county of residence in this state.