Arizona Transitional Training Permit Requirements

In 2021, Arizona lawmakers created a new type of medical licensure – the Arizona Transitional Training Permit. The permit allows certain osteopathic and allopathic medical school graduates who have not completed a residency program to provide care while working with an Arizona-licensed, supervising qualified physician.¹ 

The law requires a supervising physician to delegate, supervise, and accept responsibility for all care a permitholder provides. A supervising physician must hold an unrestricted license, cannot be under current board discipline, and can supervise only one transitional training permitholder at any one time.  

You may be wondering if hiring a transitional training permitholder would make sense for your practice. The answer depends, in part, on whether you and your practice can commit to fulfilling all the supervisory, training, and documentation requirements mandated by statute. The following FAQs will help you understand more about transitional training permits, including the specific responsibilities of supervising physicians and practices. 

Who qualifies for a transitional training permit? 

Applicants must be graduates of an allopathic or osteopathic medical school who have successfully completed steps one and two of the U.S. medical licensing exam or equivalent steps of the comprehensive osteopathic medical licensing exam. 

In addition, applicants must show that within the prior two years they: 

• Submitted a valid application to an accredited internship or residency program and were not selected; or 
  
  
• Were selected for an accredited internship or residency program but had to withdraw (reason for withdrawal cannot be one that would be considered grounds for licensing board disciplinary action). 

Is the permit renewable? 

• The permit is valid for one year and is renewable for two additional one-year periods. 
  
  
• To renew, a permitholder must submit documentation showing that he or she unsuccessfully applied to at least three accredited primary care internship or residency programs over the past year. 
  
  
• Permitholders cannot hold the permit for more than 36 months total. 

Where can a permitholder provide care? 

Care must be provided in Arizona in a: 

• Private office or clinic where the supervising physician practices; 
  
  
• Licensed hospital or behavioral health facility; 
  
  
• Patient care facility operated by or for an American Indian tribe, the Indian health service, the U.S. veterans administration, a prison, or a school or university; or  
  
  
• Community health center or federally qualified health center. 

The statute prohibits permitholders from providing care in a pain management clinic.²

What type of care can a permitholder provide? 

• A permitholder may only perform tasks delegated by the supervising physician. 
  
  
• Delegated tasks must be within the permitholder’s scope of medical training, experience, and competence. 
  
  
• Tasks should be the type that would typically be delegated in an accredited internship or residency program.  

What are the Supervising Physician’s responsibilities? 

The statute requires supervising physicians to comply with the following requirements:  

• Before any supervision occurs, notify the licensing Board. Notice must include the name of the permitholder and the name and location of the practice or other location where supervision will occur.
   
• Ensure proper delegation of all tasks the permitholder will perform. Tasks must be appropriate to the permitholder’s competence level and within the scope of his/her medical training and experience.
   
• During the first six months of the permitholder’s full-time practice, provide “direct supervision” of all clinical tasks – i.e., the physician must be physically present with the permitholder and the patient. 
   
• After six months, you may opt to provide “indirect supervision with direct supervision immediately available” for clinical encounters -i.e., the physician must be physically present and immediately available in the medical office or other site where care is provided.
   
• Review all medical records related to any clinical task performed by the permitholder.
   
• Document all supervision provided.
   
• Accept responsibility for all aspects of a permitholder’s performance (whether or not the physician employs the permitholder).
   
• If the permitholder exceeds the scope of delegated health care tasks, notify the board, the practice, and the permitholder in writing.
   

What are the statutory requirements for a medical practice or other entity where the permitholder provides care? 

In addition to the supervising physician’s duties, a medical practice (or other entity where care is provided) that employs or contracts with a permitholder must comply with the following statutory requirements:  

• Work with the supervising physician to provide the permitholder with ongoing clinical training related to tasks the physician may delegate.
   
• Accept responsibility, along with the supervising physician, for all aspects of the permitholder’s performance.
   
• Ensure that tasks performed by the permitholder are properly delegated and supervised by the physician.
   
• Ensure that the tasks delegated to and performed by the permitholder are within his/her scope of medical training, experience, and competence.
   
• Ensure all physician supervision is documented.
   
• Ensure that the permitholder is clearly identified as a medical graduate in training during all clinical or patient encounters.
   
• Define and document the relationship with the permitholder (whether as an employee, independent contractor, etc.). Include terms of compensation/benefits, billing and reimbursement details, and general and professional liability coverage information.
   
• Develop and implement a written policy and procedure that sets forth a process for periodic written evaluation of the permitholder’s performance. As part of the evaluation process, the supervising physician must review all medical records related to the clinical encounters performed by the permitholder. 

Before employing or contracting with a permitholder, the practice or other entity must provide the following information to the Arizona Department of Health Services (ADHS) on a department-approved or equivalent form: 

• The types and extent of medical training the practice will provide to the permitholder;
   
• Name(s) of the supervising physician(s); and  
  
  
• Types of health care tasks the supervising physician(s) may delegate to the permitholder.  

A practice or other entity must annually submit a report to ADHS containing the following information: 

• Number of permitholders and supervising physicians the entity contracts with or employs;
   
• Length of time the entity has contracted with/employed each permitholder and supervising physician; 
  
  
• Total number of medical education hours the practice provided to each permitholder; 
  
  
• Total number of clinical care hours each permitholder has provided; and 
  
  
• Number of permitholders who obtained a match with an accredited internship or residency program. 

The practice or other entity must also post this report on its website. 

Can a permitholder administer or dispense drugs? 

• A supervising physician may allow the permitholder to administer drugs.  
  
  
• A supervising physician may allow the permitholder to dispense drugs (in compliance with statutory dispensing requirements) under the dispensing certificate held by the physician or practice.  

Risk Management Strategies 

When hiring or contracting with a permitholder, physicians and practices should look for ways to make statutory compliance foolproof. Consider developing the following: 

• A written, standardized process to evaluate and track the permitholder’s competency level. Complete and document an initial evaluation and periodic evaluations after that (consider quarterly). Keep copies in the permitholder’s personnel file.
   
• A supervision, medical records review, and documentation policy and “workflow.” The goal is to make sure the physician can show that he/she reviewed all medical records related to clinical encounters and appropriately supervised all care provided. 
   
• A process to obtain patients’ consent to care and treatment by the permitholder. Document the discussion and consent in the medical record or use a standardized form patients sign after the discussion.
   
• A clinical training “curriculum” that includes topics and “lesson plans.”
   
• A process to track clinical care hours a permitholder provides.
   
• A process to track the number of medical education hours the practice provides a permitholder. 

If you have questions about transitional training permits or would like to schedule a medical professional liability risk consultation, please contact The Risk Team directly at 800-705-0538 or rm_info@mica-insurance.com. Our experienced Risk Consultants are standing by to answer your questions. 

^{[1] A.R.S. § 32-1432.04 (allopathic) & A.R.S. § 32-1829.01 (osteopathic).} 

^{[2] "Pain management clinic" means a health care facility or private office/clinic, where a provider issues prescriptions for opioids, benzodiazepines, barbiturates or carisoprodol (not including for medication-assisted treatment) for more than 90 days in a 12-month period to most of the patients in any month. This does not include a hospital, urgent care center, ambulatory surgical center, hospice facility or nursing care institution. A.R.S. § 36-448.01.}