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Inactive/Extension

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FOR EITHER TYPE OF REQUEST:
Requests for Inactive status and extensions of Inactive status may be submitted within the 3 months prior to the expiration date and require a $100.00 fee. If the request is submitted after the expiration date, but within 3 months, the request can be processed, but must include a $100.00 late fee. Requests cannot be accepted more than 3 months after the expiration date.

You will be notified by email of the decision regarding your request. If your request for Inactive Status is approved, you may not engage in the practice of behavioral health until you have reactivated your license pursuant to A.A.C. R4-6-305(F). 
 

Please fill out all the fields for the Inactive Fee for $100.

Customer Information
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Address

License Informaion
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Inactive/Extension
Is this your first inactive status request or an extension to a previously requested/approved inactive status request?

Per Board rule, extensions to inactive status require demonstration of good cause which is defined as: illness or disability, active military service, or a circumstance beyond the control of the licensee.  

I understand that my request must be approved at an upcoming Board meeting and I have enclosed documentation validating my Good Cause reason
One file only.
10 MB limit.
Allowed types: pdf.
No

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