Fill - Free fillable 011415HE Aplus Community Partner Application (Arizona Health Care Cost Containment System) PDF form

1

Revised03/10/2017

HEAplusCommunityPartnerApplication

PleasecompletethisapplicationandemailittoHEAAHCCCS@azahcccs.gov.Submittingthisapplicationdoesnot

guaranteeanacceptanceasacommunitypartnerorga nization; wereservetherighttorefuse partnership.

1.Nameofyourorganization:_________________________________________________________

2.URLforyourorganization’swebsite(ifany):_________________________________________

3.Brieflyprovideanexplanationofhowyourorganizationplanstousethesystem:

___________________________________________________________________________________________ 

4.Locations:Pleaseenterthename,addressandph

onenumberofeachlocationyouwanttohaveincludedinyour

HEAplusaccount.Note:Onlyspecifythelocation(s)thatwillbedirectlyutilizingtheHEAplusApplication.

NameofLocation AddressofLocation PhoneNumber

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5.TypeofOrganization(Selectone):

 ☐AHCCCSRegisteredMedicalProviderorContractor(RBHA,healthplan,FQHC,hospital,otherclinicormedical

provider)

 ☐Tribal638,IHS,UrbanIndianHealthCenterortribalsocialserviceoffice

 ☐Non‐ProfitCommunityOrganization(church,foodbank,socialservicesagency)

 ☐StateorLocalGo

vernment

 ☐Otherorganization

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Print Form

2

Revised03/10/2017

6.HEAplusCommunityPartnerAgreementContactPerson(AHCCCSwillsendtheagreementtothispersonfor

signature):

 Name:_____________________________________

Title:___________________________________

 MailingAddress:________________________________________________________________

 EmailAddress:_________________________________________

 PhoneNumber:___________________

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SITEADMINISTRATOR

YourHEAplusSiteAdministratoristhepersoninyourorganizationwhowillberesponsiblefor:

• CreatingH

EAplusaccountsforyourstaff

• ResettingHEApluspasswordsforyourstaff

• DeactivatingHEAplususeraccountswhenstaffmembersleaveyouremploymentormovetoanewpositionthat

doesnotuseHEAplus

• Keepingtheinformationforyourorganization’slocations(sites)current.

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7.Pleaseprovidethefoll

owinginformationforthepersonwhowillbeyourorganization’sSiteAdministrator:

Name:______________________________________________

PreferredUserNameforHEApluslogin:________ _____________

 MailingAddress:________________________________________________________________

 EmailAddress:___________________________

 PhoneNumber:________________

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011415HE Aplus Community Partner Application (Arizona Health Care Cost Containment System)

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