Get Exhibit 430-2

Filling out the EXHIBIT 430-2 is a crucial step in requesting commercial oral nutritional supplements for eligible members. This guide provides you with clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the EXHIBIT 430-2 online.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering the member’s AHCCCS ID number and the contracted health plan in the designated fields.
3. Fill in the member's name, date of birth, and address accurately.
4. Provide the details of the assessment performer, their AHCCCS provider ID, specialty, telephone number, and the date the assessment was conducted.
5. Select whether this is an initial or ongoing request by marking the appropriate checkbox.
6. Indicate the preferred type of nutritional supplement by writing it in the provided space and specify whether substitution is permissible.
7. Check the applicable type of nutrition feeding from the provided options that relate to the request.
8. Record the assessment findings by confirming the criteria met for medical necessity, ensuring to use supporting documentation dated no earlier than three months prior to the request.
9. For the criteria in the right column, specify which two or more have been met by checking the relevant boxes and providing information in the space allocated.
10. Ensure that both additional requirements concerning the member's evaluation and previous trials are confirmed and documented.
11. Sign the form as the submitting provider, including the printed name, date, contact number, and provider type.
12. Once completed, save changes, download, print, or share the form as required.

Complete your EXHIBIT 430-2 online today to ensure timely processing of your request.