Get Az Community Service Agency Title Xix Certification Application 2014-2025

Filling out the AZ Community Service Agency Title XIX Certification Application can be a straightforward process when approached step-by-step. This guide aims to provide clear instructions on how to complete the application thoroughly and correctly, ensuring all necessary information is included.

Follow the steps to complete the certification application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of application in the designated field, ensuring the format is correct (MM/DD/YYYY). This allows the reviewing body to track the application timeline efficiently.
3. Complete the provider information section by entering your AHCCCS Provider ID number and National Provider Identification (NPI) in the specified fields to identify your facility appropriately.
4. Fill out your provider name, phone number, and email address accurately so that the agency can reach you for any follow-up related to the application.
5. Specify the provider addresses: administrative, facility, and mailing addresses. Ensure that all fields, including city, street, and zip code, are filled in to avoid any processing delays.
6. Indicate your current and intended contracts with each T/RBHA by marking 'C' for current and 'I' for intended contracts. This section helps clarify your agency's collaborations.
7. Provide detailed information about your program director, including their name and credentials. This information is crucial for the verification process.
8. List the Tax ID number and Social Security number. Either option can be used, but ensure the information is accurate to prevent issues with your application.
9. In the provider enclosures section, check the boxes next to each document that you are including with your application. Make sure to attach all required documents, such as incorporation documents and occupancy permits.
10. In the services provided section, select all applicable services your agency offers. Use the ADHS/DBHS Covered Behavioral Health Services Guide for reference to ensure you are using accurate service codes.
11. When describing the program details, clearly state the purpose, goals, and the populations served to provide insights into the operation of your agency.
12. Complete the direct service staff member/contractor list, providing names, certification dates, and the services each individual provides.
13. Ensure that each direct service staff member or contractor's qualifications meet the requirements as outlined in the application, attaching credible evidence where necessary.
14. Finally, sign and date the application form to affirm that all information provided is truthful and complete. The application must be submitted to the relevant T/RBHA, either by mail or hand delivery.
15. Upon completion, you can save changes, download, print, or share the form as needed.

Start completing your AZ Community Service Agency Title XIX Certification Application online today for a smooth certification experience.