Section R6-6-1504.03. Contents of a Complete Application Package - Initial Certificate

An initial application package is complete when the Division has all of the following information:

1.        From the applicant, a completed application form as pre- scribed in R6-6-1504 (B); and

2.        From the applicant, the following documents listed on the application form:

a.         A completed AHCCCS provider participation agree- ment form as prescribed in R6-6-1503 which con- tains the following information:

i.         The applicant’s name, social security number or tax identification number, and business address;

ii.        Terms of the agreement between the provider and AHCCCS; and

iii.      Signature of the applicant.

b.        A completed declaration of criminal history as pre- scribed in R6-6-1504(B)(6) on a Division form which contains the following information:

i.         Name of the applicant,

ii.       Social security number,

iii.      Date of birth,

iv.      Applicant address,

v.        A declaration of whether or not the applicant has committed any of the crimes listed in R6-6- 1514, and

vi.      Dated signature.

c.         Documentation showing that fingerprints have been taken as prescribed in R6-6-1506;

d.        Documentation showing current CPR training as prescribed in R6-6-1520;

e.         Documentation showing current First Aid training as prescribed in R6-6-1520;

f.         Documentation showing Article 9 review as pre- scribed in R6-6-1520;

g.        Documentation showing that the applicant has a cur- rent driver’s license, vehicle registration, and liabil- ity insurance as prescribed in R6-6-1520(D);

h.        Copies of any applicable professional license or cer- tification as prescribed in R6-6-1504(C); and

i.         AHCCCS provider registration form as prescribed in R6-6-1503 which contains the following informa- tion:

i.         Name, social security number, and Federal Employer Identification (FEI) number of the applicant;

ii.       Physical and mailing address of the applicant;

iii.      Telephone number and telefacsimile number, if applicable for the applicant;

iv.       Categories of service provided;

v.        Changes from the prior year, if necessary;

vi.       AHCCCS provider identification number;

vii.     Districts and counties served;

viii.    Place and date of birth; and

ix.       Dated signature.

3.        From sources other than the applicant, the documents listed on the application form as follows:

a.         Three letters of reference as prescribed in R6-6- 1504(D), and

b.        Documentation showing that the applicant’s home or office has passed:

i.         A fire inspection as prescribed in R6-6-1505, and

ii.        A health and safety inspection as prescribed in R6-6-1505.

Historical Note

Adopted effective February 1, 1998 (Supp. 98-1).