Ariz. Admin. Code § R6-6-1504 - Application for an Initial Hcbs Certificate

Current through Register Vol. 27, No. 52, December 24, 2021

A. To become certified to provide a Home and Community-based Service to a client, an applicant shall file an application for an HCBS certificate with the Division and meet the requirements of this Article.
B. The applicant shall complete application for an initial HCBS certificate on a form prescribed by the Division. The form shall contain the following information:
1. Name,
2. Home and business address,
3. Specific services for which application is made,
4. Phone number,
5. Social security number or tax identification number,
6. Self declaration regarding criminal history of offenses listed in R6-6-1514(B),
7. Description of work experience, and
8. Description of educational background.
C. The applicant shall provide a copy of any other license or certificate required by this Article to provide a specific service.
D. Except as provided by R6-6-1521, the applicant shall provide forms for three letters of reference to individuals who are not the applicant's family members and who have personal knowledge about the applicant's employment history, education, or character. The letters will be on forms provided by the Division. The individual giving the reference shall send the completed reference form to the Division.
E. The Division shall be in receipt of a completed application and three letters of reference before considering certification of the applicant.
F. The applicant shall provide the Division with written documentation signed by the person performing the inspection of the completion of the requirements of R6-6-1505.
G. Within 60 days of receipt of an application, the Division shall notify the applicant of any missing documents or information. The Division shall allow 30 days from the date of notification to the applicant for submission of the remaining documents or information and, if not received at that time, may close the record.
H. The Division shall conduct background checks with Child Protective Services and Adult Protective Services on applicants when information in the application indicates a past history of child or elder abuse. The Division shall utilize the background check information when determining whether to certify an applicant.


Ariz. Admin. Code § R6-6-1504
Adopted effective February 1, 1996; filed in the Office of the Secretary of State December 26, 1995 (Supp. 95-4).

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