ARIZ
ONA STATE BOARD OF PHYSICAL THERAPY
1740 W. Adams Street, Suite 2450 • Phoenix, AZ 85007 • (602) 274 – 0236
ptboard.az.gov
Doug Ducey
Governor
Judy Chepeus
Interim Executive Director
INTERSTATE TELEHEALTH PROVIDER REGISTRATION INSTRUCTIONS
Governor Doug Ducey signed HB2454 telehealth bill which makes permanent telehealth flexibility that had been permitted under
executive order. The law takes effect immediately.
The ability to engage in telehealth services for physical therapists residing out-of-state requires the completion of the Interstate
Telehealth Provider Registration Form below. Please review the following details before completing the form.
This registration is only for purposes of providing interstate telehealth services to patients in Arizona. If you are seeking
an Arizona PT license or PTA certificate submit the appropriate application via elicense.az.gov.
This registration process is not required of AZ licensed PTs treating AZ patients.
A health care provider who is registered pursuant to this section may NOT:
Open an office in this state except as part of a multi-state provider group that includes at least one health care
provider who is licensed in this state through the Arizona State Board of Physical Therapy
Provide in-person health care services to persons located in this state without first obtaining a license through the
Arizona State Board of Physical Therapy
The registration form below provides interstate telehealth registration services to health care providers that are required to
register to provide interstate telehealth service encounters with patients in the State of Arizona. You are requesting to
register to provide telehealth services across state lines (into Arizona) which will require at a minimum that you:
Hold a current, valid, and unrestricted license in another state and are NOT subject to any past or pending
disciplinary proceedings in any jurisdiction where you hold a professional license.
Provide verification proof of all professional licenses including all US jurisdictions in which the provider is licensed
and the license numbers.
Provide evidence of Professional Liability Insurance Coverage.
Provide proof of a Duly Appointed Statutory Agent for Service of Process in Arizona.
Act in full compliance with all applicable laws and rules in this state.
Consent to this state’s jurisdiction for any disciplinary action or legal proceedings.
Follow Arizona standards of care for the physical therapy profession.
If registering as a PTA, the supervising PT must also be an interstate telehealth registrant. PTAs must include in their
registration the name and the Arizona Interstate Telehealth Provider Registration (ITP) number of the supervising PT
You DO NOT need to complete this interstate telehealth registration if either of the following applies:
1. The services are provided under one of the following circumstances:
o In response to an emergency medication condition.
o In consultation with a health care provider who is licensed in Arizona and who has the ultimate authority
over the patient’s diagnosis and treatment.
o To provide after-care specifically related to a medical procedure that was delivered in person in another
state.
o To a person who is a resident of another state, the telehealth provider is the primary care provider located
in the person’s state of residence.
2. The health care provider provides fewer than ten telehealth encounters in a calendar year.
Fees – Registration $100, non-refundable
Mail completed form, all supporting documents, and fees to:
Arizona State Board of Physical Therapy, 1740 W. Adams Street, Suite 2450, Phoenix, AZ 85007
ARIZO
NA STATE BOARD OF PHYSICAL THERAPY
1740 W. Adams Street, Suite 2450 • Phoenix, AZ 85007 • (602) 274 – 0236
ptboard.az.gov
Doug Ducey
Governor
Judy Chepeus
Interim Executive Director
INTERSTATE TELEHEALTH PROVIDER REGISTRATION FORM
Name_____________________________________________________________________________________________
Address___________________________________________________________________________________________
Email___________________________________________ Telephone_____________________________________
Urgent Situation Contact Info__________________________________________________________________________
Social Security Number_____________________________ Birthdate______________________________________
Are you a Physical Therapist Assistant (PTA)? Yes No
If you are a PTA, you must provide the Supervising Physical Therapist details:
Name_______________________________ AZ ITP Registration Number____________________________
Email Address_______________________________________________________________________________
License Verifications – List State and License number for every professional license/certificate held regardless of status.
If additional space is needed, provide separate page.
State
License/Certificate Number
State
License/Certificate Number
Initia
l the following:
_____ I affirm I am including with this registration, official verification details from my licensing board (or their
website).
Note, license verification is NOT a copy of your license, but official details obtained through your licensing board including,
but not limited to, issue date, expiration date, status, discipline history (or lack thereof).
_____ I affirm I hold a current, valid, and unrestricted license in another state.
_____ I affirm I am not subject to any past or pending disciplinary proceedings in any jurisdiction.
_____ I affirm I must notify the AZ PT Board within 5 days after any restriction or disciplinary action is initiated or
imposed on any license/certificate.
Professional Liability Insurance Coverage Required
_____ I affirm I have professional liability insurance coverage.
_____ I affirm that my liability insurance covers telehealth services provided in Arizona.
_____ I affirm I am including with this registration, proof of professional liability insurance coverage.
Duly Appointed Statutory Agent for Service of Process in Arizona Required
_____ I affirm I have a duly appointed statutory agent for service of process in Arizona.
Re
mit form, required attachments, and fees to:
ARIZONA STATE BOARD OF PHYSICAL THERAPY
1740 W. Adams Street, Suite 2450 • Phoenix, AZ 85007
_____ I affirm I am including with this registration, proof of a duly appointed statutory agent on that agent’s
letterhead.
Provide Duly Appointed Statutory Agent Contact Information:
Name_______________________________________________________________________________________
Address_____________________________________________________________________________________
Email ______________________________________ Telephone_____________________________________
Interstate Telehealth Registration Annual Update/Renewal
_____ I understand that I must update/renew this registration annually
_____ I understand that as part of my annual registration update/renewal I must submit a report to the AZ State Board
of Physical Therapy that includes the number of patients I have served in Arizona and the total number and type
of encounters in this state for the preceding year.
Signing this document affirms that the registry applicant:
• Acts 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
established by section 36-3607.
• Complies with all existing requirements of this state and any other state in which the health care provider is
licensed regarding maintaining professional liability insurance, including coverage for telehealth services
provided in this state
• Consents to this state’s jurisdiction for any disciplinary action or legal proceeding related to the health care
provider’s acts or omissions under this article
• Follows this state’s standards of care for the Physical Therapy profession
• Understands that a health care provider who is registered pursuant to this section may NOT
o Open an office in this state except as part of a multi-state provider group that includes at least one
health care provider who is licensed in this state through the Arizona State Board of Physical Therapy
o Provide in-person health care services to persons located in this state without first obtaining a license
through the Arizona State Board of Physical Therapy
• Understands that failure to comply with the applicable laws and rules of this state is subject to investigation and
both non-disciplinary and disciplinary by the Arizona State Board of Physical Therapy
Under penalty of perjury, I declare and affirm that the statements made in this interstate telehealth provider registry are
complete and correct and that any false or misleading information may be cause for denial or disciplinary action. To the
best of my knowledge and belief I am not in violation of the provisions of the Arizona Physical Therapy Law.
________________________________________________ _______________________________________
Signature Date
