1. A. An application for emergency evaluation pursuant to A.R.S. § 36-524 may be made to any evaluation agency licensed and approved by the Administration to provide such services on AHCCCS form MH-104, Titled “Application for Emergency Admission for Evaluation,” set forth in Exhibit C.

2. B. Prior to admission of an individual under this Section, the evaluation agency shall notify the appropriate health plan of the potential admission so that the health plan may first:

   1. 1. Offer and provide services or treatment to the individual as an alternative to admission; or
   2. 2. Authorize admission of the individual.
3. C. If the evaluation agency does not provide notice pursuant to subsection (B), the health plan shall not be obligated to pay for the services provided.
4. D. Only a mental health agency licensed by the Administration to provide emergency services according to A.R.S. Title 36, Chapter 4 may provide court-ordered emergency admission services under A.R.S. Title 36, Chapter 5, Article 4.

Exhibit C. Application for Emergency Admission for Evaluation

APPLICATION FOR EMERGENCY ADMISSION FOR EVALUATION

(Pursuant to A.R.S. § 36-524)

PERSONAL DATA OF PROPOSED PATIENT:

Age Date of Birth Sex Race

Weight Height Hair Color Eye Color

Marital Status Number of Children

Social Security No. Religion

Distinguishing Marks ________________________________________________________________________________________

Occupation ________________________________________________________________________________________________

Present Location ____________________________________________________________________________________________

Dates and Places of Previous Hospitalization ______________________________________________________________________

How Long in Arizona State Last From

Veteran? C-No. Education

NAME, ADDRESS AND TELEPHONE NUMBER OF:

1) Guardian

2) Spouse

3) Next of Kin

4) Significant Other Persons

DATE SIGNATURE OF APPLICANT

Printed or Typed Name of Applicant

Relationship to Proposed Patient

Applicant’s Address

Applicant’s Telephone

SUBSCRIBED AND SWORN to before me this __________ day of ______________________________, 19______.

___________________________________________________

Notary Public

My Commission Expires:

__________________________________

ADHS/BHS Form MH-104 (9/93)

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit C repealed, new Exhibit C adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Renumbered from a position after R9-21-503 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by emergency rulemaking at 28 A.A.R. 3848 (December 16, 2022), with an immediate effective date of November 28, 2022, for 180 days (Supp. 22-4). Emergency to expire May 27, 2023; amended by final rulemaking at 29 A.A.R. 898 (April 21, 2023), effective May 30, 2023 (Supp. 23-1).

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Former Section R9-21-502 renumbered to R9-21-501; new Section R9-21-502 renumbered from R9-21-503 and amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by final rulemaking at 29 A.A.R. 898 (April 21, 2023), effective May 30, 2023 (Supp. 23-1).