Section R9-15-209. Service Site Application

A.       The individual in the senior leadership position at a service site shall complete a service site application form, available from the Department, to have the Department determine service site eligibility and a priority score. The individual in the senior leadership position at the service site shall provide the com- pleted service site application to the primary care provider applying to participate in the PCPLRP. The completed service site application shall include the following information:

1.        The name and street address of the service site;

2.        The service site’s business organization type;

3.        The following information about the HPSA in which the service site is located, if known:

a.        Name,

b.        Federal identification number, and

c.        Federal degree-of-shortage ranking;

4.        The name and address of the primary care provider’s pro- spective employer, if different from the name and address of the service site;

5.        The prospective employer’s business organization type, if the prospective employer is different from the service site;

6.        A statement that the service site is in compliance with the requirements of R9-15-207;

7.        A statement that the service site has financial means available to provide the following to the primary care provider for a minimum of 24 months of full-time ser- vices:

a.        Salary,

b.        Benefits, and

c.        Malpractice insurance expenses;

8.        The service site’s Medicare identification number;

9.        The service site’s AHCCCS provider number;

10.     The notarized signature of the individual in the senior leadership position at the service site certifying that all of the information on the application is true; and

11.     The following documentation:

a.        A copy of the service site’s sliding-fee scale, and

b.        A copy of the service site’s policy for using the slid- ing-fee scale.

B.       The  Department  shall  send  a written notice of  appealable

agency action that complies with A.R.S. Title 41, Chapter 6, Article 10 to the individual in the senior leadership position at a service site that is determined to be ineligible to have a pri- mary care provider participate in the PCPLRP. If the individ- ual in the senior leadership position at the service site decides to appeal, the individual in the senior leadership position at the service site shall file a notice of appeal with the Department within 30 days after receiving the notice of appealable agency action.  The appeal  shall  be  conducted in  accordance with

A.R.S. Title 41, Chapter 6, Article 10.

Historical Note

New Section made by final rulemaking at 7 A.A.R. 2823, effective August 9, 2001 (Supp. 01-2).