SB1271 - 551R

Be it enacted by the Legislature of the State of Arizona:

Section 1. Section 32-1422, Arizona Revised Statutes, is amended to read:

START_STATUTE32-1422. Basic requirements for granting a license to practice medicine; credentials verification

A. An applicant for a license to practice medicine in this state pursuant to this article shall meet each of the following basic requirements:

1. Graduate from an approved school of medicine or receive a medical education that the board deems to be of equivalent quality.

2. Except as provided in section 32‑1432.04, successfully complete an approved twelve-month hospital internship, residency or clinical fellowship program.

3. Have the physical and mental capability to safely engage in the practice of medicine.

4. Have a professional record that indicates that the applicant has not committed any act or engaged in any conduct that would constitute grounds for disciplinary action against a licensee under this chapter.

5. Not have had a license to practice medicine revoked by a medical regulatory board in another jurisdiction in the United States for an act that occurred in that jurisdiction that constitutes unprofessional conduct pursuant to this chapter.

6. Not be currently under investigation, suspension or restriction by a medical regulatory board in another jurisdiction in the United States for an act that occurred in that jurisdiction and that constitutes unprofessional conduct pursuant to this chapter. If the applicant is under investigation by a medical regulatory board in another jurisdiction, the board shall suspend the application process and may not issue or deny a license to the applicant until the investigation is resolved.

7. Not have surrendered a license to practice medicine in lieu of disciplinary action by a medical regulatory board in another jurisdiction in the United States for an act that occurred in that jurisdiction and that constitutes unprofessional conduct pursuant to this chapter.

8. Pay all fees required by the board.

9. Complete the application as required by the board.

10. Complete a training unit as prescribed by the board relating to the requirements of this chapter and board rules. The applicant shall submit proof with the application form of having completed the training unit.

11. Have submitted directly to the board, electronically or by hard copy, verification of the following:

(a) Licensure from every state in which the applicant has ever held a medical license.

(b) All medical employment for the five years preceding application. If the applicant is employed by a hospital or medical group or organization, the board shall accept the confirmation required under this subdivision from the applicant's employer. For the purposes of this subdivision, "medical employment" includes all medical professional activities.

12. Have submitted a full set of fingerprints to the board for the purpose of obtaining a state and federal criminal records check pursuant to section 41‑1750 and Public Law 92‑544. The department of public safety may exchange this fingerprint data with the federal bureau of investigation.

B. The board may require the submission of credentials or other evidence, written and oral, and make any investigation it deems necessary to adequately inform itself with respect to an applicant's ability to meet the requirements prescribed by this section, including a requirement that the applicant for licensure undergo a physical examination, a mental evaluation and an oral competence examination and interview, or any combination thereof, as the board deems proper.

C. In determining if whether the requirements of subsection A, paragraph 4 of this section have been met, if the board finds that the applicant committed an act or engaged in conduct that would constitute grounds for disciplinary action, the board shall determine to its satisfaction that the conduct has been corrected, monitored and resolved. If the matter has not been resolved, the board shall determine to its satisfaction that mitigating circumstances exist that prevent its resolution.

D. In determining if whether the requirements of subsection A, paragraph 6 of this section have been met, if another jurisdiction has taken disciplinary action against an applicant, the board shall determine to its satisfaction that the cause for the action was corrected and the matter resolved. If the matter has not been resolved by that jurisdiction, the board shall determine to its satisfaction that mitigating circumstances exist that prevent its resolution.

E. The board may delegate authority to the executive director to deny licenses if applicants do not meet the requirements of this section.

F. Any credential information required to be submitted to the board pursuant to this article must be submitted, electronically or by hard copy, from the primary source where the document or information originated, except that the board may accept primary-source verified credentials from a credentials verification service approved by the board. The board is not required to verify any documentation or information received by the board from a credentials verification service that has been approved by the board. If an applicant is unable to provide a document or information from the primary source due to no fault of the applicant, the executive director shall forward the issue to the full board for review and determination. The board shall adopt rules establishing the criteria that must be met in order to waive a documentation requirement of this article. END_STATUTE

Sec. 2. Title 32, chapter 13, article 2, Arizona Revised Statutes, is amended by adding section 32-1432.04, to read:

START_STATUTE32-1432.04. Associate physicians; licensure; applications; rules; definitions

A. An associate physician may practice as an associate physician as follows:

1. By providing only primary care services and only in medically underserved rural or urban areas of this state.

2. Under the terms of an associate physician collaborative practice arrangement.

B. For a physician‑associate physician team working in a rural health clinic under the 1977 federal act (P.L 95‑210), as amended, relating to rural health clinic services:

1. The associate physician shall be considered a physician assistant for purposes of centers for medicare and medicaid services regulations.

2. Supervision requirements in addition to the minimum federal supervision requirement are not required.

C. For the purposes of this section, the board shall establish rules, pursuant to title 41, chapter 6, that provide for all of the following:

1. Licensure and license renewal procedures.

2. Physician supervision and collaborative practice arrangements.

3. Fees.

4. Any other matters that are necessary to protect the public and discipline professionals.

D. An application for licensure may be denied or the licensure of an associate physician may be suspended or revoked by the board in the same manner and for violating the standards prescribed by section 32‑1451 or such other standards of conduct prescribed by the board by rule. An associate physician is not required to complete more hours of continuing medical education than that of a licensed physician.

E. An associate physician shall clearly identify himself or herself as an associate physician and may use the terms "doctor", "Dr.", or "doc". An associate physician may not practice or attempt to practice without an associate physician collaborative practice arrangement as prescribed in section 32‑1459, except as otherwise provided in this section and in an emergency situation.

F. The collaborating physician is responsible at all times for the oversight of the activities of and accepts responsibility for primary care services rendered by the associate physician.

G. An associate physician's license renewal shall include verification of actual practice under a collaborative practice arrangement as prescribed in section 32‑1459 during the immediately preceding licensure period.

H. Each health insurance carrier or health benefit plan that offers or issues health benefit plans that are delivered, issued for delivery, continued or renewed in this state shall reimburse an associate physician for diagnosing, consulting or treating an insured or enrollee on the same basis that the health carrier or health benefit plan covers the service when it is delivered by another comparable mid‑level health care provider, including a physician assistant.

I. For the purposes of this section:

1. "Associate physician" means a medical school graduate who meets all of the following:

(a) Is a resident and citizen of the United States or is a legal resident alien.

(b) Has successfully completed step two of the United States medical licensing examination or the equivalent of such a step of any other board‑approved medical licensing examination either:

(i) Within the three‑year period immediately preceding application for licensure as an associate physician unless, when the three‑year anniversary occurred, the person was serving as a resident physician in an accredited residency in the United States and continued to do so within thirty days before applying for licensure as an associate physician.

(ii) Within three years before graduation from a medical school and the graduation occurred within the three‑year period immediately preceding application for licensure as an associate physician.

(d) Is proficient in the English language.

2. "Collaborative practice arrangement" means an agreement between a physician and an associate physician that meets the requirements of this section and section 32‑1459.

3. "Medical school graduate" means a person who has graduated from an approved school of medicine described in section 32‑1422.END_STATUTE

Sec. 3. Title 32, chapter 13, article 3, Arizona Revised Statutes, is amended by adding section 32-1459, to read:

START_STATUTE32-1459. Associate physicians; collaborative practice arrangements; requirements; rules; controlled substances; definitions

A. A physician may enter into collaborative practice arrangements with associate physicians. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed‑on protocols or standing orders for the delivery of health care services. Collaborative practice arrangements:

1. Shall be in writing.

2. May delegate to an associate physician the authority to administer or dispense drugs under the authority provided by and conditions of section 32‑1491.

3. Shall allow the associate physician to provide treatment as long as the delivery of the health care services is within the scope of practice of the associate physician and is consistent with that associate physician's skill, training and competence and the skill and training of the collaborating physician.

B. The collaborative practice arrangement shall contain at least the following provisions:

1. Complete names, home and business addresses, zip codes and telephone numbers of the collaborating physician and the associate physician.

2. A list of all other offices or locations besides those listed in paragraph 1 of this subsection where the collaborating physician authorizes the associate physician to prescribe.

3. A requirement that there be posted at every office where the associate physician is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an associate physician and have the right to see the collaborating physician.

4. All specialty or board certifications of the collaborating physician and all certifications of the associate physician.

5. The manner of collaboration between the collaborating physician and the associate physician, including how the collaborating physician and the associate physician will:

(a) Engage in collaborative practice consistent with each professional's skill, training, education and competence.

(b) Maintain geographic proximity, except that the collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty‑eight days per calendar year for rural health clinics as defined in 42 United States code section 1395x, as long as the collaborative practice arrangement includes alternative coverage as required by subdivision (c) of this paragraph. The geographic proximity exception applies only to independent rural health clinics, provider‑based rural health clinics if the provider is a critical access hospital as provided in 42 United States code section 1395i‑4 or provider‑based rural health clinics if the main location of the hospital sponsor is more than fifty miles from the clinic. The collaborating physician shall maintain documentation related to this requirement and present it to the board on request.

6. A description of the associate physician's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the collaborating physician authorizes the associate physician to prescribe and documentation that it is consistent with each professional's education, knowledge, skill and competence.

7. A list of any other written practice agreement of the collaborating physician and the associate physician.

8. The duration of any other written practice agreement between the collaborating physician and the associate physician.

9. A description of the time and manner of the collaborating physician's review of the associate physician's delivery of health care services, including provisions that the associate physician must submit a minimum of ten percent of the charts documenting the associate physician's delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every fourteen days.

10. A requirement that the collaborating physician, or any other physician designated in the collaborative practice arrangement, review every fourteen days a minimum of twenty percent of the charts in which the associate physician prescribes controlled substances. The charts reviewed under this paragraph may be counted in the number of charts required to be reviewed under paragraph 9 of this subsection.

C. The board shall adopt rules, pursuant to title 41, chapter 6, regulating the use of collaborative practice arrangements for associate physicians that specify:

1. Geographic areas to be covered.

2. The methods of treatment that may be covered by collaborative practice arrangements.

3. In conjunction with deans of medical schools and primary care residency program directors in this state, the development and implementation of educational methods and programs undertaken during the collaborative practice service that facilitates the advancement of the associate physician's medical knowledge and capabilities and that may lead to credit toward a future residency program for programs that deem such documented educational achievements acceptable.

4. The requirements for review of services provided under collaborative practice arrangements, including delegating authority to prescribe controlled substances.

D. The board shall adopt rules applicable to associate physicians that are consistent with guidelines for federally funded clinics. The rulemaking authority granted in this subsection does not extend to collaborative practice arrangements of hospital employees providing inpatient care within accredited hospitals as defined in section 36‑401.

E. The board may not deny, revoke, suspend or otherwise take disciplinary action against the license of a collaborating physician for health care services delegated to an associate physician if this section and the rules adopted pursuant to this section are satisfied.

F. the board shall require each physician, on licensure renewal, to identify whether the physician is engaged in any collaborative practice arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled substances, and to report to the board the name of each associate physician with whom the physician has a collaborative practice arrangement. The board may make such information available to the public. The board shall track the reported information and may routinely conduct random reviews of the collaborative practice arrangements to ensure they are carried out in compliance with this chapter and the rules adopted pursuant to this chapter.

G. A collaborating physician may not enter into a collaborative practice arrangement with more than six full‑time equivalent associate physicians or full‑time equivalent physician assistants, or any combination thereof.

H. The collaborating physician shall determine and document the completion of at least a one‑month period of time during which the associate physician practices in a setting in which the collaborating physician is continuously present before practicing when the collaborating physician is not continuously present. Board rules may not require the collaborating physician to review more than ten percent of the associate physician's patient charts or records during that one‑month period.

I. A collaborative practice arrangement under this section may not supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within an accredited hospital as defined in section 36‑401 if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.

J. A contract or other agreement may not require a physician to act as a collaborating physician for an associate physician against the physician's will. A physician may refuse to act as a collaborating physician, without penalty, for a particular associate physician. A contract or other agreement may not limit the collaborating physician's ultimate authority over any protocols or standing orders or in delegating the physician's authority to any associate physician, and a physician, in implementing such protocols, standing orders or delegation, may not violate applicable standards for safe medical practice established by a hospital's medical staff.

K. A contract or other agreement may not require any associate physician to serve as a collaborating associate physician for any collaborating physician against the associate physician's will. An associate physician may refuse to collaborate, without penalty, with a particular physician.

L. Each collaborating physician and associate physician in a collaborative practice arrangement shall wear identification badges while acting within the scope of their collaborative practice arrangement. The identification badges shall prominently display the licensure status of each collaborating physician and associate physician.

M. An associate physician who is granted controlled substances prescriptive authority as provided in this chapter may prescribe any controlled substance listed in schedule III, IV or V, and may have restricted authority in schedule II, when delegated the authority to prescribe controlled substances in a collaborative practice arrangement. Prescriptions for schedule II medications prescribed by an associate physician who has a certificate of controlled substances prescriptive authority are restricted to only those medications containing hydrocodone. Such authority shall be filed with the board. The collaborating physician may limit a specific scheduled drug or scheduled drug category that the associate physician is allowed to prescribe. Any limits shall be listed in the collaborative practice arrangement. Associate physicians may not prescribe controlled substances for themselves or members of their families. Schedule III controlled substances and schedule II hydrocodone prescriptions are limited to a five‑day supply without refill, except that buprenorphine may be prescribed for up to a thirty‑day supply without refill for patients receiving medication‑assisted treatment for substance use disorders under the direction of the collaborating physician. Associate physicians who are authorized to prescribe controlled substances under this chapter shall register with the United States drug enforcement administration and shall include the United States drug enforcement administration registration number on prescriptions for controlled substances. The collaborating physician shall determine and document the completion of at least one hundred twenty hours in a four‑month period by the associate physician during which the associate physician practices with the collaborating physician on‑site before prescribing controlled substances when the collaborating physician is not on‑site.

N. This section and section 32‑1432.04 do not limit the authority of hospitals or hospital medical staff to make employment or medical staff credentialing or privileging decisions.

O. For the purposes of this section, "associate physician" and "collaborative practice arrangement" have the same meanings prescribed in section 32-1432.04.END_STATUTE

Sec. 4. Section 32-1822, Arizona Revised Statutes, is amended to read:

START_STATUTE32-1822. Qualifications of applicant; application; fingerprinting; fees

A. On a form and in a manner prescribed by the board, an applicant for licensure shall submit proof that the applicant:

1. Is the person named on the application and on all supporting documents submitted.

2. Is a citizen of the United States or a resident alien.

3. Is a graduate of a school of osteopathic medicine approved by the American osteopathic association.

4. Except as provided in section 32‑1829.01, has successfully completed an approved internship, the first year of an approved multiple‑year residency or a board‑approved equivalency.

5. Has passed the approved examinations for licensure within seven years of application or has the board‑approved equivalency of practice experience.

6. Has not engaged in any conduct that, if it occurred in this state, would be considered unprofessional conduct or, if the applicant has engaged in unprofessional conduct, is rehabilitated from the underlying conduct.

7. Is physically, mentally and emotionally able to practice medicine, or, if limited, restricted or impaired in the ability to practice medicine, consents to contingent licensure pursuant to subsection E of this section or to entry into a program prescribed in section 32‑1861.

8. Is of good moral character.

9. Beginning September 1, 2017, Has submitted a full set of fingerprints to the board for the purpose of obtaining a state and federal criminal records check pursuant to section 41‑1750 and Public Law 92‑544. The department of public safety may exchange this fingerprint data with the federal bureau of investigation.

B. An applicant must submit with the application the nonrefundable application fee prescribed in section 32‑1826 and pay the prescribed license issuance fee to the board at the time the license is issued.

C. The board or the executive director may require an applicant to submit to a personal interview, a physical examination or a mental evaluation or any combination of these, at the applicant's expense, at a reasonable time and place as prescribed by the board if the board determines that this is necessary to provide the board adequate information regarding the applicant's ability to meet the licensure requirements of this chapter. An interview may include medical knowledge questions and other matters that are relevant to licensure.

D. The board may deny a license for any unprofessional conduct that would constitute grounds for disciplinary action pursuant to this chapter or as determined by a competent domestic or foreign jurisdiction.

E. The board may issue a license that is contingent on the applicant entering into a stipulated order that may include a period of probation or a restriction on the licensee's practice.

F. The executive director may issue licenses to applicants who meet the requirements of this section.

G. A person whose license has been revoked, denied or surrendered in this or any other state may apply for licensure not sooner than five years after the revocation, denial or surrender.

H. A license issued pursuant to this section is valid for the remainder of the calendar year in which it was issued, at which time it is eligible for renewal. END_STATUTE

Sec. 4. Title 32, chapter 17, article 2, Arizona Revised Statutes, is amended by adding section 32-1829.01, to read:

START_STATUTE32-1829.01. Associate physicians; licensure; application; rules; definitions

A. An associate physician may practice as an associate physician as follows:

1. By providing only primary care services and only in medically underserved rural or urban areas of this state.

2. Under the terms of an associate physician collaborative practice arrangement.

B. For a physician‑associate physician team working in a rural health clinic under the 1977 federal act (P.L. 95-210), as amended, relating to rural health clinic services:

1. The associate physician shall be considered a physician assistant for purposes of centers for medicare and medicaid services regulations.

2. Supervision requirements in addition to the minimum federal supervision requirement are not required.

C. For the purposes of this section, the board shall establish rules, pursuant to title 41, chapter 6, that provide for all of the following:

1. Licensure and license renewal procedures.

2. Physician supervision and collaborative practice arrangements.

3. Fees.

4. Any other matters that are necessary to protect the public and discipline professionals.

D. An application for licensure may be denied or the licensure of an associate physician may be suspended or revoked by the board in the same manner and for committing unprofessional conduct as prescribed by section 32‑1854 or violating such other standards of conduct prescribed by the board by rule. An associate physician is not required to complete more hours of continuing medical education than that of a licensed physician.

E. An associate physician shall clearly identify himself or herself as an associate physician and may use the terms "doctor", "Dr.", or "doc". An associate physician may not practice or attempt to practice without an associate physician collaborative practice arrangement as prescribed in section 32‑1862, except as otherwise provided in this section and in an emergency situation.

F. The collaborating physician is responsible at all times for the oversight of the activities of and accepts responsibility for primary care services rendered by the associate physician.

G. An associate physician's license renewal shall include verification of actual practice under a collaborative practice arrangement as prescribed in section 32‑1862 during the immediately preceding licensure period.

I. For the purposes of this section:

1. "Associate physician" means a medical school graduate who meets all of the following:

(a) Is a resident and citizen of the United States or is a legal resident alien.

(b) Has successfully completed step two of the United States medical licensing examination or the equivalent of such a step of any other board‑approved medical licensing examination either:

(ii) Within three years before graduation from a medical school and the graduation occurred within the three‑year period immediately preceding application for licensure as an associate physician.

(d) Is proficient in the English language.

2. "Collaborative practice arrangement" means an agreement between a physician and an associate physician that meets the requirements of this section and section 32‑1862.

3. "Medical school graduate" means a person who has graduated from an approved school of osteopathic medicine described in section 32‑1822.END_STATUTE

Sec. 6. Title 32, chapter 17, article 3, Arizona Revised Statutes, is amended by adding section 32-1862, to read:

START_STATUTE32-1862. Associate physicians; collaborative practice arrangements; requirements; rules; controlled substances; definitions

1. Shall be in writing.

2. May delegate to an associate physician the authority to administer or dispense drugs under the authority provided by and conditions of section 32‑1871.