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Telehealth

Telehealth Registry
Out-of-state licensed optometrists who are not licensed in Arizona and wish to provide healthcare services via telehealth to client(s) located in Arizona may wish to consider applying for the Telehealth Registry. This registration is for telehealth only, and is not a license.

For more information regarding application for a full, independent Arizona license, see the Optometry Applications page.

If you currently hold an Arizona license, you do not need to be registered in the Telehealth Registry to practice via telehealth means. An Arizona license authorizes the licensee to provide professional services to patients located in Arizona in person or via telehealth.

The Registry is authorized by A.R.S. § 36-3606.

The registration must be updated annually, and specific reporting is required under A.R.S. § 32-3606(A)(9). There is no cost to update the registration. The annual reporting form is online HERE.

See A.R.S. § 36-3606 for requirements. Please note, Board staff cannot provide an interpretation of statutory requirements. Please do an internet search or consult an attorney regarding terminology in this statute.

Applicant Information

First Name

Last Name

Phone Number

Personal Phone Number

Email

Confirm email

You will need to confirm your submission with this email

Address

City

State

Zip Code

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

Please upload evidence of possessing professional liability insurance coverage that includes coverage for telehealth services provided in Arizona.

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

Please 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.
10 MB limit.
Allowed types: pdf.

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

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

Please upload a signed statement that you have read the Arizona Revised Statutes and the Arizona Administrative Code sections that govern the practice of optometry in this state.

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

Please 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.
10 MB limit.
Allowed types: pdf.

Agreement and Signature

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.

I 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.

I agree - I understand that by signing electronically, my electronic signature is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. Under penalty of perjury, I herewith affirm that my electronic signature was signed by myself with my full knowledge and consent.

Signature

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