Get Az Pm 3.14.4 2010-2026

Filling out the AZ PM 3.14.4 form is an essential step for requesting out-of-network services in Arizona's behavioral health system. This guide will provide clear instructions on each section of the form to help you complete it accurately and effectively.

Follow the steps to fill out the AZ PM 3.14.4 form online

1. Press the ‘Get Form’ button to access the form in the online editor.
2. Begin by entering the participant's information, including their CIS number, full name, mailing address, date of birth, city, zip code, and fund type.
3. Fill in the DSM-IV diagnostic codes, ensuring to include current codes on Axes I and II, as well as information for Axes III, IV, and V.
4. Provide a clinical rationale for the referral and detail the anticipated aftercare following the requested services.
5. Indicate the network provider agency, along with the provider's phone number and the assigned network clinician's contact information.
6. In the section for requested out-of-network services, specify the reason for the out-of-network request by selecting from options such as geo-access or continuity of care.
7. Fill in the anticipated start date and provide the relevant service codes, service descriptions, frequency of service, and the number of units needed per month.
8. List the in-network providers that were contacted for the requested services and include the reasons why the services cannot be provided by these options.
9. Complete the out-of-network provider information, including their phone number, mailing address, credentials, and contact person details.
10. Ensure that the out-of-network provider is licensed as required and check all compliance questions regarding their credentials.
11. Collect the clinical director's name and signature, including the date of the signature.
12. Finally, review the completed form for accuracy, save your changes, and submit the form following the provided fax instructions.

Take action now and complete your AZ PM 3.14.4 form online to ensure timely processing of your request.