Get Az Lcr-1077a 2017-2026

Filling out the AZ LCR-1077A form is an essential step for vendor provider registration within the Division of Developmental Disabilities. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently, ensuring a smooth submission process.

Follow the steps to successfully fill out your AZ LCR-1077A form online.

1. Press the ‘Get Form’ button to access the form and open it in your browser.
2. Select the action you are requesting by checking the appropriate box. Your options include 'Initial', 'Reactivate', 'Name Change', 'Add Service', 'Delete Service', 'Change SS or EIN', or 'Change of Ownership'.
3. Enter the application date and indicate whether AHCCCS registration is required by selecting 'Yes' or 'No'.
4. If applicable, fill in your certification ID number.
5. Specify the effective date of the action you are requesting.
6. Provide your agency name and indicate whether you are a DES/DDD state employee by checking 'Yes' or 'No'.
7. Fill in your mailing address, including street, city, state, and ZIP code.
8. Enter your FEI/tax ID number, business/home phone, emergency/evening phone, and fax number.
9. In the provider profile section, enter the agency name and service/physical street address if it differs from your mailing address.
10. Select the categories of service you provide by checking the relevant boxes, along with the type of service (hourly, daily, or both).
11. Attach the required agency staff roster, LCR-1028 FORFF, or facsimile as part of your submission.
12. Sign and date the form, affirming that the information is true and accurate to the best of your knowledge.
13. Complete any additional required fields, such as place of birth and date of birth.
14. Save your changes, and then download, print, or share the completed form as needed.

Begin your online filing process for the AZ LCR-1077A form today!