Prescription Drug Diversion: Suspicious Activity Report

The below form is provided as a convenient way for health care providers (e.g. physician, pharmacist, hospital, etc.) and the general public to report suspicious activity involving prescription medication to the Arizona Attorney General's Office. For example: fraudulent, stolen, or altered prescriptions, a suspicious doctor/pharmacy or an individual obtaining prescription drugs for any purpose other than the treatment of an existing medical condition, such as for purposes of misuse, diversion, or illegal distribution.

It should be noted that submitting the form does not mean a criminal investigation will be commenced.

This information is reported directly to the AZ Attorney General’s Office and is not a complaint submittal to the AZ Board of Pharmacy. If you would like to submit a complaint to the Board, please click on this link https://pharmacy.az.gov/complaint.

Suspicious Person(s) Information (If Known)

Name

License/Registration/Certification Number (if known)

Phone

Address

Address 2

City/Town

ZIP/Postal Code

Complaint Information

Complaint Type

Briefly describe suspicious situation being reported - who, what, where, and when

Business Establishment Involved (If Any)

Name of Business/Practice

Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

(If you would like to remain anonymous,
leave the following information blank.)

Your Information

Name

Phone

Employer Information

Company

Employer Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

Prescription Drug Diversion: Suspicious Activity Report

Suspicious Person(s) Information (If Known)

Complaint Information

Business Establishment Involved (If Any)

(If you would like to remain anonymous, leave the following information blank.)

Your Information

Employer Information

(If you would like to remain anonymous,
leave the following information blank.)