The information on this page was last updated by Horty, Springer & Mattern on February 16, 2021.

ARIZONA

REPORTING REQUIREMENTS

Ariz. Rev. Stat. Ann. § 32-1451. Grounds for disciplinary action; duty to report; immunity; proceedings; board action; notice requirements

A. The board on its own motion may investigate any evidence that appears to show that a doctor of medicine is or may be medically incompetent, is or may be guilty of unprofessional conduct or is or may be mentally or physically unable safely to engage in the practice of medicine. On written request of a complainant, the board shall review a complaint that has been administratively closed by the executive director and take any action it deems appropriate. Any person may, and a doctor of medicine, the Arizona medical association, a component county society of that association and any health care institution shall, report to the board any information that appears to show that a doctor of medicine is or may be medically incompetent, is or may be guilty of unprofessional conduct or is or may be mentally or physically unable safely to engage in the practice of medicine. The board or the executive director shall notify the doctor as to the content of the complaint as soon as reasonable. Any person or entity that reports or provides information to the board in good faith is not subject to an action for civil damages. If requested, the board shall not disclose the name of a person who supplies information regarding a licensee’s drug or alcohol impairment. It is an act of unprofessional conduct for any doctor of medicine to fail to report as required by this section. The board shall report any health care institution that fails to report as required by this section to that institution’s licensing agency.

B. The chief executive officer, the medical director or the medical chief of staff of a health care institution shall inform the board if the privileges of a doctor to practice in that health care institution are denied, revoked, suspended or limited because of actions by the doctor that appear to show that the doctor is or may be medically incompetent, is or may be guilty of unprofessional conduct or is or may be mentally or physically unable to safely engage in the practice of medicine, along with a general statement of the reasons, including patient chart numbers, that led the health care institution to take the action. The chief executive officer, the medical director or the medical chief of staff of a health care institution shall inform the board if a doctor under investigation resigns or if a doctor resigns in lieu of disciplinary action by the health care institution. Notification shall include a general statement of the reasons for the resignation, including patient chart numbers. The board shall inform all appropriate health care institutions in this state as defined in § 36-401 and the Arizona health care cost containment system administration of a resignation, denial, revocation, suspension or limitation, and the general reason for that action, without divulging the name of the reporting health care institution. A person who reports information in good faith pursuant to this subsection is not subject to civil liability.

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§ 32-1855. Disciplinary action; duty to report; hearing; notice; independent medical examinations; surrender of license [Osteopathic physicians]

A. Except as otherwise provided in this subsection, the board on its own motion may investigate any information that appears to show that an osteopathic physician and surgeon is or may be guilty of unprofessional conduct or is or may be mentally or physically unable safely to engage in the practice of medicine. A physician who conducts an independent medical examination pursuant to an order by a court or pursuant to § 23-1026 is not subject to a complaint for unprofessional conduct unless, in the case of a court-ordered examination, the complaint is made or referred by a court to the board, or in the case of an examination conducted pursuant to § 23-1026, the complaint alleges unprofessional conduct based on some act other than a disagreement with the findings and opinions expressed by the physician as a result of the examination. Any osteopathic physician or surgeon or the Arizona osteopathic medical association or any health care institution as defined in § 36-401 shall, and any other person may, report to the board any information the physician or surgeon, association, health care institution or other person may have that appears to show that an osteopathic physician and surgeon is or may be guilty of unprofessional conduct or is or may be mentally or physically unable safely to engage in the practice of medicine. The board shall notify the doctor about whom information has been received as to the content of the information as soon as reasonable after receiving the information. Any person who reports or provides information to the board in good faith is not subject to civil damages as a result of that action. If requested the board shall not disclose the informant’s name unless it is essential to the disciplinary proceedings conducted pursuant to this section. It is an act of unprofessional conduct for any osteopathic physician or surgeon to fail to report as required by this section. The board shall report any health care institution that fails to report as required by this section to that institution’s licensing agency. A person who reports information in good faith pursuant to this subsection is not subject to civil liability. For the purposes of this subsection, “independent medical examination” means a professional analysis of medical status that is based on a person’s past and present physical, medical and psychiatric history and conducted by a licensee or group of licensees on a contract basis for a court or for a workers’ compensation carrier, self-insured employer or claims processing representative if the examination was conducted pursuant to § 23-1026.

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§32-1855.03 Health care institution duty to report; immunity; patient records; confidentiality

A. A health care institution as defined in section 36-401 or a subscription provider of health care shall report to the board any information it may have that appears to show that an physician may be guilty of unprofessional conduct or may be mentally or physically unable safely to engage in the practice of medicine. A health care institution or subscription provider of health care that provides information to the board in good faith is not subject to an action for civil damages as a result and, if requested, the board shall not disclose its name unless the testimony is essential to the disciplinary proceedings pursuant to §32-1855. The board shall report a health care institution or subscription provider of health care that fails to report as required by this section to the institution’s licensing agency.

B. The chief executive officer, the medical director or the medical chief of staff of a health care institution or subscription provider of health care shall inform the board when the privileges of an physician to practice in the health care institution or subscription provider of health care are denied, revoked, suspended or limited because of actions by the physician that jeopardized patient health and welfare or when the physician resigned during pending proceedings for denial, revocation, suspension or limitation of his privileges. A report to the board pursuant to this subsection shall contain a general statement of the reasons the health care institution or subscription provider of health care took an action to deny, revoke, suspend or limit a physician’s privileges.

C. Hospital records, medical staff records, medical staff review committee records and testimony concerning these records and proceedings related to the creation of these records are confidential and are subject to the same discovery and use in legal actions only as are the original records in the possession and control of hospitals, their medical staff and their medical staff review committees. The board shall use these records and testimony only during the course of investigations and proceedings pursuant to this chapter.

D. Patient records, including clinical records, medical reports, laboratory statements and reports, any file or film, any other report or oral statement relating to diagnostic findings or treatment of patients, any information from which a patient or the patient’s family might be identified or information received and records kept by the board as a result of the investigation made pursuant to this chapter are confidential.

E. Nothing in this chapter or any other provision of law relating to privileged communications between a physician and his patient applies to investigations or proceedings conducted pursuant to this chapter. The board and its employees, agents and representatives shall keep confidential the name of a patient whose records are reviewed during the course of an investigation and proceedings.

 

 This substantive policy statement is advisory only. A substantive policy statement does not include internal procedural documents that only affect the internal procedures of the agency and does not impose additional requirements or penalties on regulated parties or include confidential information or rules made in accordance with the Arizona administrative procedure act. If you believe that this substantive policy statement does impose additional requirements or penalties on regulated parties you may petition the agency under Arizona Revised Statutes section 41-1033 for a review of the statement.

ARIZONA MEDICAL BOARD

SUBSTANTIVE POLICY STATEMENT #13 [Adopted June 5, 2008]

DUTIES OF HOSPITALS AND PHYSICIANS TO REPORT

PEER REVIEW/QUALITY ASSURANCE INFORMATION

The Arizona Medical Board issues this Substantive Policy Statement to notify the public of the Board’s interpretation of A.R.S. § 32-1451, its interrelationship with A.R.S. § 36-445 (Peer Review) et seq., A.R.S. § 36-2401 (Quality Review) et seq. and A.R.S. § 36-2917 and to clarify the reporting requirements to the Arizona Medical Board for physicians and institutions as defined by these statutes.

Statutory Overview:

According to A.R.S. § 32-1451(A):

A doctor of medicine, the Arizona Medical Association, a component county society of that association and any health care institution shall report to the Board “any information that appears to show that a doctor of medicine is or may be medically¹ incompetent, is or may be guilty of unprofessional conduct² or is or may be mentally or physically unable safely to engage in the practice of medicine (collectively ‘Reportable Information’).”

According to A.R.S. § 32-1451(B):

The chief executive officer (“CEO”), the medical director and the chief of staff of a health care institution shall report to the Board “if the privileges of a doctor to practice in that health care institution are denied, revoked, suspended or limited because of actions by the doctor that appear to show that a doctor of medicine is or may be medically incompetent, is or may be guilty of unprofessional conduct² or is or may be mentally or physically unable safely to engage in the practice of medicine, along with a general statement of the reasons, including patient chart numbers, that led the health care institution to take action.”

Duty to Report:

The Board recognizes the importance of interpreting A.R.S. § 32-1451, A.R.S. § 36-445 et seq., A.R.S. § 36-2401 et seq. and A.R.S. § 36-2917 consistently to give effect to all of these statutory provisions. The Board further recognizes the importance of Peer Review and Quality Review processes in health care institutions and that prematurely reporting to the Board may have an unintended effect on the Peer Review and Quality Review processes required by law.

The Board interprets A.R.S. § 32-1451(B) to provide that the following constitute Reportable Information that doctors of medicine, hospitals, and outpatient surgical centers are required to promptly report to the Arizona Medical Board:

• After the CEO, medical director, chief of staff or other medical staff officer has requested that a member of the medical staff refrain from exercising his/her medical staff privileges in lieu of being suspended or having his/her privileges otherwise restricted during an investigation of possible medical incompetence, unprofessional conduct under A.R.S. §32-1401(27), or mental or physical inability to safely engage in the practice of medicine.
• After a medical staff committee determines that information received by such committee about a doctor of medicine, who is not a member of the medical staff, suggests medical incompetence, unprofessional conduct under A.R.S. 32-1401(27), or that the physician is unable to safely engage in the practice of medicine.
• Whenever a hospital, outpatient surgical center or medical staff committee has, following a brief assessment, information that appears to be credible and shows that a doctor of medicine is or may be unable safely to practice medicine because of substance abuse or other physical or mental impairment.

The Board interprets A.R.S. § 32-1451(A) to require other health care entities and individual allopathic physicians to report Reportable Information promptly:

• A doctor of medicine, the Arizona Medical Association, a component county society of that association and any health care institution shall report to the Board, any information that appears to be credible and shows that a doctor of medicine is or may be medically incompetent, is or may be guilty of unprofessional conduct or is or may be mentally or physically unable safely to engage in the practice of medicine.
• After the chair of the Quality Review Committee, the CEO, medical director, chief of staff or any other medical staff officer has requested that a doctor of medicine refrain from practice pending an investigation for medical incompetence, unprofessional conduct under A.R.S. 32-1401(27), or mental or physical inability to safely engage in the practice of medicine.
• After the health care entity terminates or otherwise limits the ability of a doctor of medicine to practice in or for the health care entity for medical incompetence, unprofessional conduct under A.R.S. 32-1401(27), or mental or physical inability to safely engage in the practice of medicine.
• Whenever a health care entity, medical director or any other officer of such health care entity has, following a brief assessment, information that appears to be credible and shows that a doctor of medicine is or may be unable safely to practice medicine because of substance abuse or other physical or mental impairment.

The Board does not interpret A.R.S. § 32-1451 to require a health care institution or doctor of medicine to report information obtained about a doctor of medicine during and for the purposes of the Peer Review or Quality Review processes, unless action is taken as outlined above. The Board understands that to require such reporting would greatly impair the smooth functioning of the Peer Review and Quality Assurance processes and, thus, such a requirement would be inconsistent with A.R.S. § 36-445 et seq., A.R.S. § 36-2401 et seq. and A.R.S. § 36-2917.

The Board interprets A.R.S. 32-1451(B) to require, at the least, that a health care institution’s Medical Director or designee report to the Arizona Medical Board promptly after a medical staff committee recommends to the governing board of the institution that a doctor of medicine have his or her membership or privileges revoked, suspended or limited even if the doctor of medicine has the right to request a fair hearing to challenge the recommendation.

Nothing in this Substantive Policy statement precludes a person or entity from submitting information to the Board before a peer review process begins, or earlier in a peer review process than circumstances described herein occur. A.R.S. §32-1451(A) states “[a]ny person or entity that reports or provides information to the board in good faith is not subject to an action for civil damages. If requested, the board shall not disclose the name of a person who supplies information regarding a licensee’s drug or alcohol impairment.”

The Board does not interpret A.R.S. §32-1451 to require duplicative reports to be filed describing the same information by different persons or entities. If one person or entity with a duty to report information to the Board makes a report describing such information, the Board will not require a second person or entity with a duty to report to file a duplicative report describing the same information. However, the health care institution’s Medical Director is responsible for ensuring a report has been made under A.R.S. §32-1451(B).

Summary:

This Substantive Policy Statement is issued by the Arizona Medical Board to clarify the duty of doctors of medicine as well as any health care institution to promptly report to the Board as required by statute any information that appears to show that a doctor of medicine is or may be medically incompetent, is or may be guilty of unprofessional conduct¹ is or may be unable to safely engage in the practice of medicine because of substance abuse or other physical or mental impairment.

¹See A.R.S. § 32-1401(18)

²See A.R.S. § 32-1401(27)

¹See A.R.S. 32-1401(27)