Get Initial Dialysis Case Creation Form Please ... - Ahcccs - Azahcccs

Filling out the Initial Dialysis Case Creation Form is an essential step in providing necessary documentation for individuals diagnosed with end-stage renal disease. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to efficiently complete the form.

1. Click 'Get Form' button to obtain the form and open it in your document editor.
2. Begin by entering the member's name in the designated field. Ensure that you print their full name clearly.
3. Next, input the date of birth for the member. This should be formatted as MM/DD/YYYY to maintain consistency.
4. Fill in the AHCCCS ID number for the member in the appropriate section. This number is crucial for patient identification.
5. In the following section, describe the patient's health condition as diagnosed with end-stage renal disease (ESRD). Make sure this aligns with their medical records.
6. State your medical opinion regarding the necessary dialysis treatments per week. Specify the number clearly in the designated area.
7. You must then sign the form, confirming the information is accurate as the treating physician. Include your signature and the date of signing.
8. Provide your AHCCCS provider ID number in the appropriate field to verify your credentials.
9. Indicate the dialysis start date, which is required only for initial certification. Use the format MM/DD/YYYY.
10. Finally, select the dialysis facility name from the list or write it down in the provided space.
11. Once you have completed all sections, save your changes. You may also download, print, or share the form as needed before submission.

Complete your documentation and submit the form online to ensure timely processing of your patient's care.