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Get AZ DD-097-1-FF 2012-2024

Er and the individual and/or responsible party receiving services prior to the initiation of services. A copy MUST be retained by the provider and a copy sent to the District Office. The provider must also ensure that a General Consent and Authorization form is completed and retained by the provider. PROVIDER INFORMATION PROVIDER’S NAME (Last, First, M.I.) EMPLOYER TAX NO. AHCCCS ID NO. IS THERE ANY SPECIAL TRAINING REQUIRED? Yes No Describe: Med Training Needed Yes No Seizure Managemen.

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