Arizona Administrative Code
Section R6-6-1504.03 - Contents of a Complete Application Package - Initial Certificate

Universal Citation: AZ Admin Code R 6-6-1504.03

Current through Register Vol. 30, No. 12, March 22, 2024

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.

Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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