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Agency Name AZ.gov Arizona's Official Web Site
Controlled Substances
Prescription Monitoring Program
       Established 1903
Contact Information

Dean Wright
CSPMP Director
Phone: (602) 771-2744
E-mail: dwright@azpharmacy.gov

Cindi Hunter
CSPMP Manager
Phone: (602) 771-2732
E-mail: chunter@azpharmacy.gov

 

Arizona State Board of Pharmacy
Physical Address:
1616 W. Adams, Suite 120
Phoenix, AZ 85007-2835
Fax: (602) 771-2748

Mailing Address:
P.O. Box 18520
Phoenix, AZ 85005

 

 


Affidavit Submission Requirements

When requesting database access, a law enforcement, licensing board, or AHCCCS investigator who has a user name and password must complete an affidavit verifying authority, purpose, and subject of the data requested. The notarized affidavit must be faxed or mailed to ASBP within two days of a web query for data.  The affidavit must include ALL six requirements that include:

The state and county in which affidavit is executed.

  1. The state and county in which affidavit is executed.
  2. The name of the individual requesting the information, direct phone number or e-mail address as well as the individual’s job description and the agency represented. The affiant must also state that the affiant is over the age of 18 years.
  3. Include time-frame for the search, primary name (and any known AKA’s) and   DOB (if a patient) or DEA number (if a medical practitioner) of the subject being investigated.
  4. A statement that the information requested is pursuant to an open complaint or investigation. (Required by Arizona Administrative Code § 36-2604(C) (3), (4), or
    (5)).
  5. A statement that the names, addresses and other identifying information included in the request relate to the subject being investigated.
  6. Signature of affiant and notarization.

Fax to: 602-771-2748

 

Sample Affidavits:


AHCCCS Affidavit sample

Board Affidavit sample

Law Enforcement Affidavit sample