Ariz. Admin. Code § R6-6-1504.03 - Contents of a Complete Application Package - Initial Certificate

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

An initial application package is complete when the Division has all of the following information:

1. From the applicant, a completed application form as prescribed in R6-6-1504(B); and

2. From the applicant, the following documents listed on the application form:

a. A completed AHCCCS provider participation agreement form as prescribed in R6-6-1503 which contains the following information:

i. The applicant's name, social security number or tax identification number, and business address;

ii. Terms of the agreement between the provider and AHCCCS; and

iii. Signature of the applicant.

b. A completed declaration of criminal history as prescribed in R6-6-1504(B)(6) on a Division form which contains the following information:

i. Name of the applicant,

ii. Social security number,

iii. Date of birth,

iv. Applicant address,

v. A declaration of whether or not the applicant has committed any of the crimes listed in R6-6-1514, and

vi. Dated signature.

c. Documentation showing that fingerprints have been taken as prescribed in R6-6-1506;

d. Documentation showing current CPR training as prescribed in R6-6-1520;

e. Documentation showing current First Aid training as prescribed in R6-6-1520;

f. Documentation showing Article 9 review as prescribed in R6-6-1520;

g. Documentation showing that the applicant has a current driver's license, vehicle registration, and liability insurance as prescribed in R6-6-1520(D);

h. Copies of any applicable professional license or certification as prescribed in R6-6-1504(C); and

i. AHCCCS provider registration form as prescribed in R6-6-1503 which contains the following information:

i. Name, social security number, and Federal Employer Identification (FEI) number of the applicant;

ii. Physical and mailing address of the applicant;

iii. Telephone number and telefacsimile number, if applicable for the applicant;

iv. Categories of service provided;

v. Changes from the prior year, if necessary;

vi. AHCCCS provider identification number;

vii. Districts and counties served;

viii. Place and date of birth; and

ix. Dated signature.

3. From sources other than the applicant, the documents listed on the application form as follows:

a. Three letters of reference as prescribed in R6-6-1504(D), and

b. Documentation showing that the applicant's home or office has passed:

i. A fire inspection as prescribed in R6-6-1505, and

ii. A health and safety inspection as prescribed in R6-6-1505.

Notes

Ariz. Admin. Code § R6-6-1504.03

Adopted effective February 1, 1998 (Supp. 98-1).