Fillable PT Committee Application Fillable Form (Arizona Health Care Cost Containment System)

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PT Committee Application Fillable Form (Arizona Health Care Cost Containment System)

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The PT Committee Application Fillable Form (Arizona Health Care Cost Containment System) form is 3 pages long and contains:

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AHCCCS P&T Committee Application for Appointment
AHCCCS P&T Committee Application - 1/1/2016 Page 1 of 3
Instructions: Please complete this application for consideration for membership on the AHCCCS P&T Committee. If
questions are not applicable, enter “NA”. Note: in addition to this application, applicants should include a resume
and/or curricula vitae.
Type of Application:
Initial Appointment
Reappointment
Position applying for (select category then choose from dropdown):
Health care provider
Other:___________________________________________________
Members of the public
AHCCCS Managed Care Organizations (MCOs) and Regional
Behavioral Health Authority (RBHA) representatives:
PERSONAL INFORMATION
1. Name
_____________________________ _____________________________ ____________________________
LAST FIRST MIDDLE
Address (street or post office box)
___________________________________________ _____________________________________________
ADDRESS CITY
_______ _______________________ _______________________________________________________
STATE ZIP COUNTY
2. Contact
___________________________ ___________________________ _____________________________
HOME PHONE OFFICE PHONE MOBILE
__________________________________________________ ____________________________________
EMAIL FAX
3. Current Employment Not Applicable
___________________________________________ _____________________________________________
BUSINESS/ORGANIZATION NAME CURRENT POSITION/TITLE
___________________________________________ _____________________________________________
ADDRESS CITY
_______ _______________________ _______________________________________________________
STATE ZIP PHONE
Select One
Select One
Select One
AHCCCS P&T Committee Application for Appointment
AHCCCS P&T Committee Application - 1/1/2016 Page 2 of 3
4. Professional Licenses, Registrations, Certifications and/or Experience:
5. Experience with AHCCCS Programs:
6. Are you currently an AHCCCS registered provider? Yes No
CONFLICT OF INTEREST DISCLOSURE
The AHCCCS Pharmacy and Therapeutics Committee (P&T) members, applicants and persons speaking or
presenting to the Committee are asked to disclose any financial or other affiliation with organizations that may
have a direct or indirect interest in the business in front of the Committee. Members of the P&T Committee
disclose potential conflicts annually.
A financial interest may include, but is not limited to, being a shareholder in the organization, being on retainer with the
organization, or having research or honoraria paid by the organization or receiving other forms of remuneration from an
organization.
An affiliation may include holding a position on an advisory committee or some other role or benefit to a
supporting organization.
AHCCCS P&T Committee Application for Appointment
AHCCCS P&T Committee Application - 1/1/2016 Page 3 of 3
The existence of such financial relationships or affiliation does not necessarily constitute a conflict of interest and
will not preclude an individual from participating or addressing the P&T Committee. This policy is intended to
openly identify any potential conflicts so that the P&T Committee members are able to form an unbiased
judgment of the specific drug or therapeutic class being evaluated.
Please check the box of the statement that best applies:
Statement of No Conflicts
I do not have a current or recent (within the last 24 months) financial arrangement or affiliation with any
organization that may have a direct interest in the business before the AHCCCS P&T Committee.
Disclosures
I have a financial interest, affiliation or am employed by an organization that may have a direct interest in
the business before the AHCCCS P&T Committee.
Organization
(List additional on the back of the form if necessary.)
Role / Relationship
(List additional on the back of the form if necessary.)
Name_________________________________________________ Date_______________________________
Signature_____________________________________________________________________________________
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PT Committee Application Fillable Form (Arizona Health Care Cost Containment System)

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Completed 23 July 2020

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