Form LCR-1025A FORFF "Application for Initial Hcbs Certification" - Arizona

What Is Form LCR-1025A FORFF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LCR-1025A FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form LCR-1025A FORFF "Application for Initial Hcbs Certification" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
LCR-1025A FORFF (06-18)
Page 1 of 2
Division of Developmental Disabilities
Office of Licensing Certification and Regulation (OLCR)
Home and Community Based Services (HCBS)
APPLICATION FOR INITIAL HCBS CERTIFICATION
Complete all questions accurately and legibly. Falsification and/or omission of information may result in delay or denial
(A.A.C. R6-6-1514) of HCBS certification.
Applicant’s Name (Last, First, M.I.) Agency’s Name (if applicable)
List all Prior Names Used
SOC. SEC. No./FEIN/Tax ID No.
Business/Home Phone No.
Applicant’s Signature
Date
1. Have you ever been licensed/certified to care for children/adults? If yes, dates, state, and
Yes
No
type (e.g., day care,ACYF,) of license/certification and attach copy if available.
From:
To:
State:
Type:
2. Have you ever had a license/certificate denied, revoked or suspended?
Yes
No
(If yes, attach an explanation.)
3. Have you ever been subject of inquiry by Division of Child Safety (DCS) or Adult
Yes
No
Protective Services (APS)? (If yes, attach an explanation.)
4. If services are to be delivered in facility/residence of the applicant, has any adult
Yes
No
N/A
household member been subject of inquiry by DCS and/or APS? (If yes, attach an
explanation.)
5. Have you ever been registered to provide services for AHCCCS?
Yes
No
If yes, what is/was your AHCCCS number?
6. Have you ever worked for or are you currently working for an AHCCCS-certified agency?
Yes
No
If yes, name of agency/facility
From:
To:
7. Are you currently Medicare-certified?(For Home Health Agencies Only) Attach copy if
Yes
No
N/A
available.
8. Does person with developmental disabilities live in the same residence as the applicant?
Yes
No
WORK HISTORY (NOT REQUIRED FOR PARENT OR IMMEDIATE FAMILY MEMBER)
List most recent job first or attach resume.
Employer’s Name
May We Contact Your Supervisor
Yes
No
Phone No.
Address (No., Street)
City
State
ZIP Code
Supervisor’s Name (Last, First)
Length of Employment (From/To) From:
To:
Job Title/Occupation
Job Duties
See page 2 for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
LCR-1025A FORFF (06-18)
Page 1 of 2
Division of Developmental Disabilities
Office of Licensing Certification and Regulation (OLCR)
Home and Community Based Services (HCBS)
APPLICATION FOR INITIAL HCBS CERTIFICATION
Complete all questions accurately and legibly. Falsification and/or omission of information may result in delay or denial
(A.A.C. R6-6-1514) of HCBS certification.
Applicant’s Name (Last, First, M.I.) Agency’s Name (if applicable)
List all Prior Names Used
SOC. SEC. No./FEIN/Tax ID No.
Business/Home Phone No.
Applicant’s Signature
Date
1. Have you ever been licensed/certified to care for children/adults? If yes, dates, state, and
Yes
No
type (e.g., day care,ACYF,) of license/certification and attach copy if available.
From:
To:
State:
Type:
2. Have you ever had a license/certificate denied, revoked or suspended?
Yes
No
(If yes, attach an explanation.)
3. Have you ever been subject of inquiry by Division of Child Safety (DCS) or Adult
Yes
No
Protective Services (APS)? (If yes, attach an explanation.)
4. If services are to be delivered in facility/residence of the applicant, has any adult
Yes
No
N/A
household member been subject of inquiry by DCS and/or APS? (If yes, attach an
explanation.)
5. Have you ever been registered to provide services for AHCCCS?
Yes
No
If yes, what is/was your AHCCCS number?
6. Have you ever worked for or are you currently working for an AHCCCS-certified agency?
Yes
No
If yes, name of agency/facility
From:
To:
7. Are you currently Medicare-certified?(For Home Health Agencies Only) Attach copy if
Yes
No
N/A
available.
8. Does person with developmental disabilities live in the same residence as the applicant?
Yes
No
WORK HISTORY (NOT REQUIRED FOR PARENT OR IMMEDIATE FAMILY MEMBER)
List most recent job first or attach resume.
Employer’s Name
May We Contact Your Supervisor
Yes
No
Phone No.
Address (No., Street)
City
State
ZIP Code
Supervisor’s Name (Last, First)
Length of Employment (From/To) From:
To:
Job Title/Occupation
Job Duties
See page 2 for EOE/ADA/LEP/GINA disclosures
LCR-1025A FORFF (06-18)
Page 2 of 2
WORK HISTORY (NOT REQUIRED FOR PARENT OR IMMEDIATE FAMILY MEMBER)
List most recent job first or attach resume. (CONTINUED)
Employer’s Name
May We Contact Your Supervisor
Yes
No
Phone No.
Address (No., Street)
City
State
ZIP Code
Supervisor’s Name (Last, First)
Length of Employment (From/To) From:
To:
Job Title/Occupation
Job Duties
BACKGROUND
Highest Grade Completed
Degree
Describe any special skills, professional licenses, training and/or previous experience with children/adults related to the
service you want to provide (i.e., babysitting, volunteer, companion, organized sports/recreation, day care, camps, nursing
homes, hospitals, and working with disabled individuals and indicate length of experience in years)
Routing: ORIGINAL – LCR (2HF1); COPY – HCBS/District Office; COPY – HCBS Applicant
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.
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