Section R4-40-301. Application

A.      An applicant or legal representative shall apply for admission to ASVH by submitting a completed ASVH application to the admissions coordinator. If both a veteran and the veteran’s spouse are applying for admission, both shall file separate applications. An application may be obtained from the ASVH at 4141 N. Third St., Phoenix, AZ 85012, telephone number [phone], or from the agency web site at www.azdvs.gov.

B.       In addition to the ASVH application required under subsection (A), an applicant or legal representative shall submit the fol- lowing:

1.        Information regarding the applicant’s ability to partici- pate in daily living activities and the applicant’s psycho- social behavior. The information may be provided through either of the following:

a.        A functional questionnaire form provided by ASVH that is completed by the applicant or family member, or

b.        The equivalent medical information provided by a health care provider;

2.        A completed applicant’s financial information statement on a form provided by ASVH;

3.        A completed physician’s statement by the applicant’s physician on a form provided by ASVH or equivalent medical information;

4.        A copy of the veteran’s discharge document from the United States military, a certified copy of the separation or discharge document issued by the National Personnel Records Center, or a Statement of Service issued by the VA Regional Office;

5.        If requested by the director of nursing, a copy of medical records that assist in determining the level of care required by the applicant. Medical records may include physician’s records, nurses’ notes, test results, and medi- cation records; and

6.        Evidence of freedom from infectious pulmonary tubercu- losis as specified by A.A.C. R9-10-908(6).

C.      Evidence of treatment at a VA Medical Center will satisfy the requirement in (B)(4) of this Section.

Historical Note

Adopted effective January 2, 1996 (Supp. 96-1).

Amended by final rulemaking at 10 A.A.R. 2990, effec- tive September 11, 2004 (Supp. 04-3). Amended by final

rulemaking at 14 A.A.R. 2709, effective August 2, 2008

(Supp. 08-2).