Get Community Service Agency Title Xix Certification - Arizona ... - Azdhs

This guide provides detailed instructions for users looking to complete the Community Service Agency Title XIX Certification Renewal Application in Arizona. It aims to simplify the process and ensure that all required information is accurately provided.

Follow the steps to complete the certification application online.

1. Press the ‘Get Form’ button to access the certification document in your online editor.
2. Begin by filling out the provider information section. Include the date of renewal, provider name, AHCCCS Provider ID, National Provider Identification (NPI), and the provider phone number.
3. Provide the administrative and facility addresses, ensuring you fill in the city, state, county, and zip code accurately for both locations.
4. Indicate the programs your agency has contracts with by marking 'C' for each current contract and 'I' for intended contracts in the specified areas.
5. List the services your agency offers, such as transportation, self-help services, and any other applicable programs that require Title XIX Certification.
6. Complete the program description, detailing the goals, objectives, and target populations served by your agency.
7. Compile a list of direct service staff members or contractors, along with their credentials, including CPR certification and fingerprint clearance details.
8. Collect all required enclosures as indicated in the application, such as incorporation documents and inspection certificates, ensuring you check each box.
9. Once all fields are filled in and required documents are attached, review your application for accuracy and completeness.
10. Sign the application form in the designated space for the provider director and the T/RBHA reviewer, then prepare to submit it either by mail or in person.

Complete your Community Service Agency Title XIX Certification Renewal Application online today.