Arizona Health Care Cost Containment System Forms

This document is for attesting to the quality of alternate care sites in Arizona that are owned and operated by Indian Health Service (IHS) or Tribal organizations.

This Form is used for certifying grant reporting in compliance with the Federal Funding Accountability and Transparency Act (FFATA) in the state of Arizona.

This document is a form that allows individuals to apply for access to the Arizona Health-E-Arizona Plus program, a state program that provides health-related services and benefits.

This document is an audit tool used for the Direct Care Worker (DCW) Training and Testing Program in Arizona. It helps ensure that the program is meeting its objectives and adhering to quality standards.

This document is used for verifying the testing of direct care workers in the state of Arizona. It is an attachment to another form or document.

This curriculum crosswalk helps to identify competencies for direct care workers in Arizona who work with individuals with developmental disabilities. It helps to ensure that these workers have the necessary skills and knowledge to provide quality care and support to people with developmental disabilities.

This document is a tool used to conduct an audit of the Direct Care Worker (DCW) Training and Testing Program in Arizona during the first year. It helps to ensure compliance and quality in the training and testing provided to DCWs.

This form is used for onsite auditing of the Direct Care Worker (DCW) Training and Testing Program in the state of Arizona.

This document is used for external users in Arizona to affirm certain statements.

This document is used for authorizing electronic funds transfers in the state of Arizona.

This Form is used for requesting prior authorization for fee-for-service medical services in Arizona. It requires medical documentation to support the need for the requested service.

This document is an amendment to a contract with Magellan in Arizona. It contains changes or updates to the original contract.

This Form is used for authorizing the release of protected health information to Ahcccs in Arizona. It is in Spanish and the text is in large letters.

This document is a quarterly certification form used by the state of Arizona to verify their non-federal matching funds for a specific project or program.

This document is a sample format of a cover letter for a claim submission, specifically for use in Arizona. It provides guidance on how to structure and format the letter when making a claim.

This document provides a profile of non-emergency transportation providers in Arizona. It includes information about the types of services they offer and the regulations they must comply with.

This document provides a profile of a provider offering Non-Emergency Medical Transportation (NEMT) services for equine patients in the state of Arizona.

This document provides a profile of a Transportation Network Company (TNC) in the state of Arizona. It gives information about the type of services they offer and their operating policies.

This form is used for making corrections to prior authorizations in the Tribal Health Program in Arizona.

This Form is used for submitting medical documentation for prior authorization through the Tribal Health Program in Arizona.

This form is used to request prior authorization for medical services under the Tribal Health Program in Arizona.

This type of document provides a profile for companies offering attendant care services in Arizona. It includes information about the company's background, services provided, and contact details.

This Form is used for enrolling healthcare providers in the state of Arizona. It is the official document required for providers to participate in state healthcare programs and receive reimbursement for services provided.

This type of document is used to authorize the release of protected medical information to Ahcccs in Arizona.

This Form is used for authorizing Ahcccs to disclose protected health information about your health in Arizona. This document is in Spanish and has large font.

This type of document is an affirmation statement for external users of the Arizona Health Care Cost Containment System (AHCCCS).

This form is used for submitting a request to the American Indian Medical Home in Arizona. It serves as a cover sheet for faxing the application.

This form is used for new members to sign up for the American Indian Medical Home program in Arizona.

This document is a sign-up form for American Indian individuals who wish to become members of the Medical Home program in Arizona. The form is available in Spanish.