1. 1. From the applicant, a completed application form as prescribed in R6-6-1504 (B); and

2. 2. From the applicant, the following documents listed on the application form:

   1. a. A completed AHCCCS provider participation agreement form as prescribed in R6-6-1503 which contains the following information:

      1. i. The applicant’s name, social security number or tax identification number, and business address;
      2. ii. Terms of the agreement between the provider and AHCCCS; and
      3. iii. Signature of the applicant.

   2. b. A completed declaration of criminal history as prescribed in R6-6-1504(B)(6) on a Division form which contains the following information:

      1. i. Name of the applicant,
      2. ii. Social security number,
      3. iii. Date of birth,
      4. iv. Applicant address,
      5. v. A declaration of whether or not the applicant has committed any of the crimes listed in R6-6-1514, and
      6. vi. Dated signature.
   3. c. Documentation showing that fingerprints have been taken as prescribed in R6-6-1506;
   4. d. Documentation showing current CPR training as prescribed in R6-6-1520;
   5. e. Documentation showing current First Aid training as prescribed in R6-6-1520;
   6. f. Documentation showing Article 9 review as prescribed in R6-6-1520;
   7. g. Documentation showing that the applicant has a current driver’s license, vehicle registration, and liability insurance as prescribed in R6-6-1520(D);
   8. h. Copies of any applicable professional license or certification as prescribed in R6-6-1504(C); and

   9. i. AHCCCS provider registration form as prescribed in R6-6-1503 which contains the following information:

      1. i. Name, social security number, and Federal Employer Identification (FEI) number of the applicant;
      2. ii. Physical and mailing address of the applicant;
      3. iii. Telephone number and telefacsimile number, if applicable for the applicant;
      4. iv. Categories of service provided;
      5. v. Changes from the prior year, if necessary;
      6. vi. AHCCCS provider identification number;
      7. vii. Districts and counties served;
      8. viii. Place and date of birth; and
      9. ix. Dated signature.

3. 3. From sources other than the applicant, the documents listed on the application form as follows:

   1. a. Three letters of reference as prescribed in R6-6-1504(D), and

   2. b. Documentation showing that the applicant’s home or office has passed:

      1. i. A fire inspection as prescribed in R6-6-1505, and
      2. ii. A health and safety inspection as prescribed in R6-6-1505.

An initial application package is complete when the Division has all of the following information:

Historical Note

Adopted effective February 1, 1998 (Supp. 98-1).