Fillable Attendant Care Company (Arizona Health Care Cost Containment System)

Fill Online, Printable, Fillable, Blank Attendant Care Company (Arizona Health Care Cost Containment System) Form

Use Fill to complete blank online ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Attendant Care Company (Arizona Health Care Cost Containment System)

On average this form takes 8 minutes to complete

The Attendant Care Company (Arizona Health Care Cost Containment System) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arizona Health Care Cost Containment System

BROWSE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PROVIDER TYPE PROFILE
PROVIDER
TYPE
40 ATTENDANT CARE * (PAGE 1 OF 2)
COMPANIES ONLY
REIMBURSE-
MENT TYPE
02 FEE FOR SERVICE
EFFECTIVE 10-01-88
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY 28 ATTENDANT CARE
MANDATORY
OPTIONAL 23 HOMEMAKER
OPTIONAL 26 RESPITE CARE
OPTIONAL 31 NON EMERGENCY
TRANSPORTATION
PROOF OF VEHICLE INSURANCE
NOTE: COS 31 UNAVAILABLE FOR 12
MONTHS AFTER APPROVAL.
OPTIONAL 39 PERSONAL CARE
OPTIONAL 43 SPECIALIZED SERVICES (EFFECTIVE 10/1/03)
OPTIONAL 47 MENTAL HEALTH SERVICES (EFFECTIVE 04/01/08)
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
SPECIAL INSTRUCTIONS: Companies are required to comply with training and recordkeeping
standards for Direct Care Workers as outlined in the AHCCCS Medical Policy Manual, Chapter 1200,
Section 1240-A. Documentation must be made available to AHCCCS and Contractors upon request.
As a part of the registration process the owner/provider is required to disclose each employees’
name, social security number, employment begin date, employment end date (if applicable), and
date of birth information using the 2nd page of this form. All staffing changes must be reported
within 30 days.
In addition, the Non-Emergency Transportation category of service will be unavailable for
Attendant Care providers for the first year after approval. Additionally, after the first year, this
provider type will be permitted to provide a minimum of 70% or more Attendant Care services
and can provide no more than 30% Non-Emergency Transportation Care. This requirement only
applies to Fee For Service providers and does not apply to registered providers who are
contracted with a Managed Care Organization.
Company Name___________________________ ID Number_______________
Signature_________________________________ Date_____________________
REVISED 6/01/2015
PROVIDER TYPE PROFILE
PROVIDER
TYPE
40
ATTENDANT CARE * (PAGE 2 OF 2)
COMPANIES ONLY
REIMBURSE-
MENT TYPE
02
FEE FOR SERVICE
EFFECTIVE 10/01/1988
List of Employees
(ALL FIELDS ARE MANDATORY)
Last Name:
First Name, Middle Initial:
SSN:
Employment Begin Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
SSN:
Employment Begin Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
SSN:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
SSN:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
SSN:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Copy if additional pages are needed. REVISED 1/9/2015
This information is required in accordance with 42 CFR 455 Subparts B and E and State Medicaid Director Letters
08-003 & 09-001.
Reset
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Attendant Care Company (Arizona Health Care Cost Containment System)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document