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Form NumberForm NameEffective DatePDFWord
AAA-1048A Monthly Ombudsman Data Collection 03/01/2010 75kbs
AAA-1050A Volunteer Commitment 09/01/2009 22kbs
AAA-1053A Client Agreement and Authorization 06/01/2009 43kbs
AAA-1054A Authorization for Release of Confidential Information and Representation 07/01/2009 35kbs
AAA-1059A Conflict of Interest Statement 09/01/2009 107kbs
AAA-1062A Adult Protective Services Intake Report 04/01/2010 180kbs
AAA-1062AS Informe de Admisión Sobre los Servicios de Protección al Adulto 04/01/2010 203kbs
AAA-1064A Case Notes 07/01/2009 75kbs
AAA-1083A Individual Employment Plan (IEP) 09/01/2012 132 KB
AAA-1084A SCSEP Assessment Guide 02/01/2011 200kbs
AAA-1085A Authority to Release Information 08/01/2006 46KBS
AAA-1100A SCSEP Participant Handbook 11/01/2011 279 KB
AAA-1100A-S SCSEP Participant Handbook (Spanish) 01/01/2011 366kbs
AAA-1116A Host Agency Supervisor's Evaluation 08/01/2007 205kbs
AAA-1117A Applicant's Confidential Statement of Income 01/01/2011 274kbs
AAA-1118A Physical Examination Statement 01/01/2011 92kbs
AAA-1119A Community Service Assignment Description 01/01/2011 126kbs
AAA-1120A Participant Evaluation 08/01/2007 224kbs
AAA-1121A Host Agency Monitoring and Safety Check 01/01/2011 146kbs
AAA-1122A Host Agency Application 01/01/2011 192kbs
AAA-1123A Agreement for Community Service Assignment 01/01/2011 171kbs
AAA-1163A Ombudsman Case 04/01/2011 213kbs
AAA-1174A SHIP/SMP Volunteer Application 02/01/2009 1290kbs
AAA-1178A Training Record 09/01/2009 65kbs
AAA-1179A Volunteer Reference Check 12/01/2010 51kbs
AAA-1180A Volunteer Application 08/01/2011 99kbs
AAA-1182A Arizona Nutrition, Wellness, and Food Service Manual 07/28/2009 1263kbs
AAA-1184A Ombudsman Designation Checklist 09/01/2014 52 KB
AAA-1185A FCSP Non-Registered Services Monthly Report 02/01/2010 27kbs
AAA-1186A FCSP Registered Services Monthly Report 02/01/2010 38kbs
AAA-1188A Long Term Care Ombudsman Manual 03/23/2011 2329kbs
AAA-1189A Long Term Care Ombudsman Volunteer Manual 03/23/2011 1597kbs
AAA-1190A Volunteer Reference Check 09/01/2010 62kbs
AAA-1194A SHIP Evaluation 02/01/2010 111kbs
AAA-1195A Volunteer Tracking and Management: Volunteer Hours 02/01/2010 39kbs
AAA-1196A Volunteer Tracking and Management: Add A Volunteer 02/01/2010 69kbs
AAA-1198A Group Session Post Survey 02/01/2010 63kbs
AAA-1198A-S Group Session Post Survey (Spanish) 02/01/2010 64kbs
AAA-1199A SHIP/SMP Client Contact 04/01/2010 278kbs
AAA-1204A Volunteer Performance Evaluation 05/01/2010 70kbs
AAA-1210A Request for Supportive Services 01/01/2011 55kbs
AAA-1211A Request for Durational Limit Waiver 01/01/2011 38kbs
AAA-1216A Mature Worker Program Quarterly Report 02/01/2011 84kbs
AAA-1217A Monthly Legal Services Assistance Report 10/01/2012 150 KB
AAA-1218A Arizona Family Caregiver Support Program (FCSP) Quarterly Summary Report 12/01/2011 43 KB
AAA-1222A Telephone Assistance Program (TAP) Checksheet 03/01/2015 43 KB
AAA-1222AS Programa de Assistencia Telefónica Hoja de Instrucciones al Cliente 03/01/2015 44 KB
AAA-1223A Senior Discount Telephone Program 06/01/2011 144kbs
AAA-1223AS Senior Discount Telephone Program (Spanish) 06/01/2011 154kbs
AAA-1226A On-the-Job Experience (OJE) Training Plan 11/01/2011 41 KB
AAA-1227A On-the-Job Experience (OJE) Reimbursement Contract 11/01/2011 49 KB
AAA-1228A On-the-Job Experience (OJE) Letter of Agreement (Direct Pay Model) 11/01/2011 48 KB
AAA-1229A Ombudsman Volunteer Evaluation - Six Month Follow-up 01/01/2012 19 KB
AAA-1230A Exit Interview Questionnaire 01/01/2012 18 KB
AAA-1233A Senior Community Service Employment Program (SCSEP) Handbook - Host Agency 05/01/2012 692 KB
AAA-1234A Disease Prevention and Health Promotion Services Quarterly Report Summary 06/01/2012 74 KB
AAA-1238A Host Agency Supervisor's Evaluation - Corrective Action Plan 10/01/2012 44 KB
AAA-1240A Disease Prevention and Health Promotion Services Quarterly Summary Report 10/01/2012 66 KB
AAA-1247A Short Form Intake Document (SFID) 11/01/2014 915 KB
AAA-1253A Ombudsman Re-Designation Checklist 09/01/2014 51 KB
AAA-1254A Ombudsman De-Designation Recommendation 09/01/2014 50 KB
AAA-1261A Adult Protective Service Registry Check 03/01/2015 102 KB
AG-030-A-FF Congregate Meals Report 07/01/2009 130kbs
AG-030-B-FF Home Delivered Meals Report 07/01/2009 126kbs
AG-031-N Social Service Report and Instructions for Non-Registered Services 08/01/2012 42 KB
AG-031-R Social Service Report and Instructions for Registered Services 03/01/2010 33kbs
AG-095 Arizona Standardized Client Assessment Plan (ASCAP) 11/01/2014 1362 KB
AG-119 Determine Your Nutritional Health 11/01/2008 175KBS
AG-119-S Determine your Nutritional Health (Spanish) 11/01/2008 140KBS
AH-800 AHCCCS Information for Applicants 10/28/2010 30kbs
AH-800S ¿Qué Servicios Cubre el Seguro de Salud de AHCCCS? 10/28/2010 29kbs
CC-001 Application for Child Care Assistance 07/01/2011 174kbs
CC-001-A Child Care Assistance Rights and Responsibilities 07/01/2015 63 KB
CC-001-S Solicitud de Asistencia para Cuidado de Niños 07/01/2011 185kbs
CC-004-FF Accident, Illness or Injury Report (Eng/Span) 09/01/2012 67 KB
CC-005-FF Log of Accidents, Injuries or Illnesses (Eng/Span) 09/01/2011 77 KB
CC-011 Information for Prospective Family Child Care Providers 07/01/2010 25kbs
CC-011-S Información para Posibles Familias Proveedoras de Cuidado de Niños en sus Hogares 07/01/2010 26kbs
CC-016-PD Priority Waiting List: What You Need to Know 03/01/2015 174 KB
CC-016-PDS Lista Prioritaria de Espera para Asistnecia con el Cuidado de Niños: Lo que Necesita Saber 03/01/2015 167 KB
CC-023 Paid Absence Policy (Eng/Span) 02/01/2008 98 KB
CC-024-FF Employment and Wage Verification Statement 12/01/2012 165 KB
CC-031-FF Verbal Notice of Eligibility (Eng/Span) 02/01/2015 121 KB
CC-033-PD Backup Agreement 11/01/2012 24 KB
CC-033-PDS Acuerdo Sobre Proveedores Remplazantes 11/01/2012 26 KB
CC-036-FF Permission to Give Medication 12/01/2012 127 KB
CC-036-FFS Permiso para Administrar Medicamentos 12/01/2012 128 KB
CC-037-FF Statement of Physical and Mental Health for Family and Child Care Providers (Eng/Span) 10/01/2012 59 KB
CC-038 Adult/Child Ratios in DES Certified Family Child Care Homes (Eng/Span) 04/01/2010 19kbs
CC-039-FF Medical Statement 08/01/2015 65 KB
CC-039-FFS Certificación Médica 08/01/2015 63 KB
CC-046 DES Child Care Services Information 07/01/2011 63kbs
CC-046-S DES Child Care Services Information (Spanish) 07/01/2011 59kbs
CC-200 Certified Child Care Provider Application 03/01/2015 363 KB
CC-200-A-FF Certified Family Child Care Provider Application (Addendum) 09/01/2011 83 KB
CC-200-A-FFS Anexo a la Solicitud Para Ser Certificado Como Un Proveedor Familiar De Cuidaco De Niño 09/01/2011 87 KB
CC-200-S Solicitud de Certificación como Proveedor Familiar de Cuidado de Niños 03/01/2015 305 KB
CC-201 Certification Statement for Providing Child Care Services 08/01/2014 48 KB
CC-201-S Declaración de Certificación para proveer servicios de cuidado de niños 08/01/2014 59 KB
CC-201A Registration & Employment History for Providing DES Certified Services (Eng/Span) 06/01/2007 24 KB
CC-218 Sign-In / Sign-Out Record 07/01/2014 122 KB
CC-218-A Sign-In / Sign-Out Record (Extended Version) 03/01/2015 129 KB
CC-218-A-S Registro de Entradas y Salidas (Versión extendida) 03/01/2015 126 KB
CC-218-S Registro de Entradas y Salidas 07/01/2013 119 KB
CC-221-FF Family Child Care Provider Statement of Services 09/01/2011 81 KB
CC-221-FFS Declaración de Servicios del Proveedor de Cuidado en Casa de Familia 09/01/2011 83 KB
CC-229 (FY15) Child Care Assistance Gross Monthly Income Eligibility Chart and Fee Schedule (FY15) 02/01/2015 131 KB
CC-229 (FY16) Child Care Assistance Gross Monthly Income Eligibility Chart and Fee Schedule FY16) 10/01/2015 43 KB
CC-229-S (FY15) Tabla de Ingresos Mensuales para Elegibilidad y las Tarifas de Pago por Cuidado de Niños (FY15) 02/01/2015 126 KB
CC-229-S (FY16) Tabla de Ingresos Mensuales Para Elegibilidad Y Las Taridas de Pago Por Cuidado de Niños (FY16) 10/01/2015 40 KB
CCA-1015A Withdrawal or Termination Request 03/01/2012 51 KB
CCA-1015AS Petición de Retiro o Terminació 03/01/2012 52 KB
CCA-1021A Unpaid Co-payment Worksheet 11/01/2011 282 KB
CCA-1021S Informe de Copagos Atrasados 11/01/2011 284 KB
CCA-1095A State of AZ Substitute W-9 form-Request for Taxpayer Identification and Certification 04/01/2004 27kbs
CCA-1095AS State of AZ Substitute W-9 form-Request for Taxpayer Identification and Certification (Spanish) 04/01/2004 32kbs
CCA-1101A What is Regulated Child Care in Arizona? 04/01/2015 157 KB
CCA-1101A-S ¿Qué es el Cuidado de Niños Regulado en Arizona? 04/01/2015 316 KB
CCA-1116A (FY15) Child Care Priority Waiting List Income Table (FY15) 10/01/2014 164 KB
CCA-1116A (FY16) Child Care Assistance Priority Waiting List Income Table (FY16) 10/01/2015 69 KB
CCA-1140A Direct Deposit Enrollment - Centers and Group Homes 04/01/2013 49 KB
CCA-1141A Direct Deposit Enrollment - DES Certified Homes/Relative Providers 04/01/2013 39 KB
CCA-1141AS Inscripción con Depósito Directo para Proveedores o Parientes Autorizados Po el DES 04/01/2013 40 KB
CCA-1161A Self-Sufficiency Statement 01/01/2011 37kbs
CCA-1161A-S Declaración de Autosuficiencia 01/01/2011 42kbs
CCA-1163A Affidavit of Immunization Exemption - For Household Members Age 13 and Younger 09/01/2011 72 KB
CCA-1163AS Affidávit de Exendión de Vacunación - Para Miembros del Hogar de 13 años de edad y Menores 09/01/2011 76 KB
CCA-1164A Affidavit of Immunization Exemption - For Children in Care 09/01/2011 67 KB
CCA-1164AS Affidávit de Exención de Vacunación - Para Menores Bajo Cuidado 09/01/2011 67 KB
CCA-1170A Withdrawal or Termination Request for Child Care Providers 08/01/2012 68 KB
CCA-1170AS Petición para el Retiro o Terminación de Solicitud - Para Proveedores de Cuidado de Niños 08/01/2012 72 KB
CCA-1175A Landlord Permission to Operate Child Care Business 04/01/2013 63 KB
CCA-1175AS Autorización para Operar un Negocio de Cuidado de Niños 04/01/2013 71 KB
CCA-1176A Parent/Guardian Affidavit of Non-Compensated Child Care 02/01/2013 66 KB
CCA-1176AS Declaración Jurada del Padre o Tutor por Cuidado de Niños no Remunerado 02/01/2013 139 KB
CCA-1186A Authority to Release Information 09/01/2014 58 KB
CCA-1194A Information Needed to Determine Eligibility for Child Care Assistance 25 KB
CMDP Dental Matrix CMDP Dental Matrix 04/30/2015 405 KB
CPS_Disq_Acts CPS Central Registry Disqualification Acts 08/02/2012 15 KB
CRS Application English Application for Enrollment into AHCCCS CRS 09/01/2013 24 KB
CRS Application Spanish Solicitud de Inscripción en los CRS de AHCCCS 09/01/2013 61 KB
CS-016-FF Certified Public Expenditures Statement 11/01/2013 87 KB
CS-124 Request for IV-D Services/Genetic Testing Agreement 10/01/2013 89 KB
CS-127-PF Acknowledgment of Paternity (Eng/Span) 03/03/2014 294 KB
CS-167 Request for Title IV-D Child Support Services 04/01/2015 601 KB
CS-167-A Child Supplemental Page / Página suplemental de menor 03/01/2015 61 KB
CS-167-S Solicitud del Título IV-D para servicios de Sustento de menores y los Derechos y Responsabilidades del solicitante 04/01/2015 603 KB
CSA-1070A Domestic Violence Transitional Housing Performance Measures 06/01/2012 91 KB
CSE-1016A Waiver of Paternity Affidavit 10/01/2013 143 KB
CSE-1016A-S Declaración Jurada de Exención de Paternidad 10/01/2013 161 KB
CSE-1091A Notification of Change of Address / Notificación de Cambio de Dirección 10/01/2013 390 KB
CSE-1129A Electronic Payment Authorization 04/01/2015 232 KB
CSE-1129A-S Autorización para pagos electrónicos 04/01/2015 233 KB
CSE-1155A Quick Reference to Reporting Requirements for Employers 08/01/2015 64 KB
CSE-1156A Affidavit of Receipt of Direct Payments / Afidávit del Recibo de Pagos Directos 03/01/2015 271 KB
CSE-1157A Non-Custodial Parent Request for Administrative Review 05/01/2014 864 KB
CSE-1157A-S Solicitud de Padre/Mare Sin la Custodia para Una Revisión Adminstrativa 05/01/2014 634 KB
CSE-1158A Request for Review of Arrears 04/01/2015 528 KB
CSE-1158A-S Solicitud para Revisión de Atrasos 04/01/2015 927 KB
CSE-1160A Request to Close Child Support Case 03/01/2015 231 KB
CSE-1160A-S Solicitud para Cerrar el Caso de Sustento de Menores 03/01/2015 230 KB
CSE-1162A Wage Transmittal Example 06/01/2014 15 KB
CSE-1163A Employer Address Information 01/01/2014 71 KB
CSE-1171A Affidavit of Financial Information (Eng/Span) 02/01/2014 142 KB
CSE-1178A Child Support Modification Packet 01/01/2014 314 KB
CSE-1178AS Paquete de Modificaciones del DCSS 01/01/2014 189 KB
CSE-1194A Do You Pay Child Support? Are You Unemployed? Come to a Child Support Modification Workshop! 04/01/2015 43 KB
CSE-1194AS ¿Paga usted Sustento para Menores? ¿Está usted desempleado? ¡Venga a un Taller de Modificación de Sustento para Menores! 04/01/2015 50 KB
CSE-1196A Notification of Employment Termination 06/01/2015 55 KB
CSE-1249A Father Matters Referral 09/01/2015 71 KB
CSO-1004A Fax Notification Form 07/01/2014 43 KB
CSO-1006A Dentist's Certification of Medical Necessity 07/01/2014 39 KB
CSO-1016A Client Grievance - Level I, with Information Regarding Client Grievances 09/01/2014 67 KB
CSO-1016A-S Queja del Cliente - Nivel I, con Información sobre Quejas de los Clientes 09/01/2014 77 KB
CSO-1017A Client Grievance - Level II 09/01/2014 57 KB
CSO-1017A-S Queja del Cliente - Nivel II 09/01/2014 67 KB
CSO-1018A Client Grievance - Level III 09/01/2014 58 KB
CSO-1018A-S Queja del Cliente - Nivel III 09/01/2014 68 KB
CSO-1026A Long Term Foster Care Agreement 08/01/2014 33 KB
CSO-1026A-S Acuerdo de Crianza Temporal a Largo Plazo 08/01/2014 52 KB
CSO-1028A Guardianship Subsidy Application 03/01/2015 55 KB
CSO-1028A-S Solicitud para Subsidio de Tutela 03/01/2015 54 KB
CSO-1029A Notice Requesting In-Home Intervention 08/01/2014 57 KB
CSO-1029A-S Aviso de Petición de una Intervención en el Hogar 08/01/2014 57 KB
CSO-1030A Electronic Funds Transfer Authorization Agreement 07/01/2015 321 KB
CSO-1032A Independent Living Program Savings Match Agreement 08/01/2014 38 KB
CSO-1033A Independent Living Subsidy Program Agreement and Approval 02/01/2015 114 KB
CSO-1036A DCS Records Request 01/01/2015 89 KB
CSO-1036A-S Solicitud de Expediente del DCS 01/01/2015 86 KB
CSO-1041A Adoptive Parent(s)' Release of Identifying Information 08/01/2014 49 KB
CSO-1042A Birth Parent(s)' Release of Identifying Information 10/01/2014 48 KB
CSO-1042A-S Autorización de la Madre/Padre Biológico para Compartir Información Identificadora 10/01/2014 50 KB
CSO-1052A Consent of Department to Adoption 08/01/2014 45 KB
CSO-1060A Adoption and Title 8 Permanent Guardianship Information 09/01/2014 27 KB
CSO-1060A-S Información de Adopción y Tutela Permanente de Título 8 09/01/2014 29 KB
CSO-1064A Independent Living Program - Request for Education Incentive Payment to Youth 10/01/2014 37 KB
CSO-1065A Referral for Guardianship 06/01/2015 116 KB
CSO-1067A Family History 02/01/2015 448 KB
CSO-1090A Foster Adoption Agreement 10/01/2014 57 KB
CSO-1098A Housing Assistance Referral 01/01/2015 104 KB
CSO-1099A Quick Reference for Prior Authorization 12/01/2014 171 KB
CSO-1109A Family Foster Home and Fees Schedule 09/01/2014 75 KB
CSO-1123A Overview of Department of Child Safety Decision Making Process 10/01/2014 64 KB
CSO-1125A Protective Services Review Team (PSRT) - Standard Cases 07/01/2015 26 KB
CSO-1125A-S Equipo de Revisión de los Servicios de Protección (PSRT por sus siglas en inglés) - Casos estándar 07/01/2015 28 KB
CSO-1130A Self-Disclosure Statement for Kinship Foster Caregiver Household 09/01/2014 107 KB
CSO-1130A-S Declaración Auto-divulgada de los Miembros del hogar para ser un Encargado de Crianza Temporal Proporcionada por Parientes 09/01/2014 124 KB
CSO-1131A Interstate Central Registry Release of Information 11/01/2014 78 KB
CSO-1131A-S Registro Central Interstatal Liberación de Información 11/01/2014 80 KB
CSO-1138A Visitation Guidelines for Parents 02/01/2015 41 KB
CSO-1138A-S Guías para las Visitas de los Padres 02/01/2015 43 KB
CSO-1141A Notice of Rights for a Child in Out-of-Home Care 01/01/2015 153 KB
CSO-1145A Affidavit of Potential Fathers (Eng/Span) 09/01/2014 78 KB
CSO-1151A Significant Incident (Eng/Span) 01/01/2015 52 KB
CSO-1153A Readiness for Change Model 05/01/2015 395 KB
CSO-1166A Prior Authorization Guidelines 05/01/2015 2323 KB
CSO-1174A Parent Insurance Release/Assignment 09/01/2014 87 KB
CSO-1174A-S Asignación y divulgación de Información para Seguros por Parte de los Padres 09/01/2014 87 KB
CSO-1175A Prior Authorization for Therapies 09/01/2014 93 KB
CSO-1176A Physician's Certification of Medical Necessity 09/01/2014 46 KB
CSO-1177A Prior Authorization for Medical Equipment and/or Supplies 09/01/2014 85 KB
CSO-1178A Concurrent Review (Continuation) 09/01/2014 29 KB
CSO-1179A Prior Authorization for Medical/Surgical Services 09/01/2014 73 KB
CSO-1180A Hospital Review Worksheet 09/01/2014 72 KB
CSO-1183A General/Pediatric Dentist Orthodontic Treatment Referral 09/01/2014 41 KB
CSO-1184A PCP Statement of Medical Necessity - Orthodontia 09/01/2014 38 KB
CSO-1190A Cultural Competency in Health Care 09/01/2014 35 KB
CSO-1191A Consideration Factors for Orthodontic Services 09/01/2014 72 KB
CSO-1197A Choosing A Health Care Provider 04/01/2015 32 KB
CSO-1198A CMDP Disenrollment Information 09/01/2014 80 KB
CSO-1199A CMDP / MedImpact Preferred Drug List - Effective April 1, 2014 09/01/2014 328 KB
CSO-1203A CMDP Enrollment/Application for Medical Assistance Funding 09/01/2014 292 KB
CSO-1204A CMDP Family Planning Services 09/01/2014 852 KB
CSO-1204A-S Servicios de planificación familiar ofrece de CMDP 09/01/2014 865 KB
CSO-1207A MedImpact Synagis Statement of Medical Necessity 09/01/2014 395 KB
CSO-1220A MedImpact Prior Authorization for Medications 10/01/2009 284 KB
CSO-1229A Criminal History Self Disclosure Affidavit 09/01/2015 48 KB
CSO-1229A-S Afidavit de Auto Revelación de la Historial Criminal 09/01/2015 50 KB
CSO-1232A Health Self-Disclosure 06/01/2015 67 KB
CSO-1232A-S Auto Declaración de Salud 06/01/2015 68 KB
CSO-1236A Initial Application Worksheet (For Applicants NOT Using Quick Connect) 06/01/2015 452 KB
CSO-1236A-S Hoja de trabajo para Solicitud Inicial (para solicitantes que NO están usando Quick Connect) 06/01/2015 464 KB
CSO-1237A Applicant Statement of Understanding 06/01/2015 60 KB
CSO-1237A-S Declaración de Comprensión del Solicitante para Licencia de Hogar de Cuidado de Crianza Temporal 06/01/2015 67 KB
CSO-1238A Foster Home License Suspension, Denial or Revocation Hearing Request 04/01/2015 57 KB
CSO-1242A On-Going Professional Development Plan 02/01/2015 54 KB
CSO-1262A Guardianship Subsidy Conditions 07/01/2015 58 KB
CSO-1262A-S Condiciones del Subsidio por Tutela 07/01/2015 55 KB
CSO-1264A Overcapacity Placement Request 03/01/2015 80 KB
CSO-1269A Physician's Statement 06/01/2015 42 KB
CSO-1269A-S Declaración del Médico 06/01/2015 44 KB
CSO-1270A Family Foster Home Licensing Initial Application Checklist 06/01/2015 48 KB
CSO-1270A-S Hoja de verificación para Solicitud Inicial de Licencia para Hogar de Cuidado de Crianza Temporal 06/01/2015 56 KB
CSO-1275A Foster Care/Adoption Assessment Guide 06/01/2015 365 KB
CSO-1275A-S Cuidado de Crianza Temporal / Adopción Guía de Evaluación 416 KB
CSO-1277A Partnership Development Plan for Individualized Support and Traning 09/01/2015 42 KB
CSO-1282A Child Welfare Licensing Prequalification 08/01/2015 83 KB
DCS-1039A Notice of Privacy Practices 08/01/2014 49 KB
DCS-1039A-S Aviso Sobre las Prácticas de Confidencialidad 08/01/2014 58 KB
DCS-1040A HIPAA Privacy Complaints 08/01/2014 51 KB
DCS-1040A-S Formulario de Queja Acerca de Privacidad de HIPAA 08/01/2014 50 KB
DCS-1041A HIPAA Privacy Complaint Confirmation of Receipt 08/01/2014 40 KB
DCS-1041A-S Constancia de Recibo de Quejas de Violacion a la Privacidad Bajo la HIPAA (Ley de Privacidad y Portabilidad de Seguro Médico, pro sus siglas en inglés) 08/01/2014 43 KB
DCS-1042A Response to HIPAA Privacy Complaint 08/01/2014 40 KB
DCS-1042A-S Respuesta a Queja de Violación a la Privacidad Bajo la HIPAA (Ley de Privacidad y Portabilidad de Seguro Médico, por sus siglas en inglés) 08/01/2014 44 KB
DCS-1043A Individual's Request for Access to Protected health Information (PHI) 02/01/2015 70 KB
DCS-1043A-S Solicitud de Acceso a Información Médica Confidencial (PHI por sus siglas en inglés) 02/01/2014 78 KB
DCS-1044A Authorization for Disclosure of Protected Health Information (PHI) 08/01/2014 49 KB
DCS-1044A-S Authorización para la Divulgación de la Información Protegida de Salud (PHI) 08/01/2014 57 KB
DCS-1045A Request for Amended/Correction of Protected Health Information (PHI) 08/01/2014 60 KB
DCS-1045A-S Solicitud de Enmienda/Corrección de Información de Salud Confidencial (PHI) 08/01/2014 64 KB
DCS-1046A Request for Restriction of Protected Health Information (PHI) 08/01/2014 54 KB
DCS-1046A-S Solicitud de Restricción de Información de Salud Confidencial (PHI) 08/01/2014 61 KB
DCS-1047A Request for Alternative Means of Communication Protected Health Information (PHI) 08/01/2014 56 KB
DCS-1047A-S Solicitud de Médios de Comunicación Alternativos Información de Salud Confidential (PHI) 08/01/2014 58 KB
DCS-1048A Request for Suspension of Accounting of Disclosures of Protected Health Information (PHI) 08/01/2014 50 KB
DCS-1048A-S Solicitud de Suspensión del Informe de Información de Salud Confidencial Divulgada 08/01/2014 58 KB
DCS-1049A Accounting of Disclosures of Protected Health Information (PHI) 08/01/2014 59 KB
DCS-1049A-S Informe de Información de Salud Confidencial Divulgada (PHI) 08/01/2014 62 KB
DCS-1050A Accounting Disclosure Tracking 08/01/2014 60 KB
DCS-1050A-S Planilla de Seguimiento Sobre Divulgación de Información de Contabilidad 08/01/2014 67 KB
DCS-1051A Request for an Accounting of Disclosures of Protected Health Information (PHI) 08/01/2014 50 KB
DCS-1051A-S Solicitud de Informe de la Información Confidencial de Salud Divulgada (PHI) 08/01/2014 52 KB
DCS-1183A Request for Search of Central Registry for Background Check 07/01/2015 297 KB
DD-023-FF Application for Eligibility Determination 07/01/2008 58kbs
DD-023-FFS Application for Eligibility Determination (Spanish) 07/01/2008 59kbs
DD-024 Developmental Foster Home Progress Report 12/01/2006 84KBS
DD-090-FF DDD Billing Information 10/01/2009 82 KB
DD-097-1-FF Pre-Service Provider Orientation 09/01/2012 176 KB
DD-097-1-FFS Orientación Previa al Servicios para Proveedores 09/01/2012 186 KB
DD-099-A-FF Pre-PAS Screening Tool Ages 7 Months Through 2 Years 09/01/2006 38kbs
DD-099-B-FF Pre-PAS Screening Tool Ages 3 Through 5 Years 09/01/2006 38kbs
DD-099-C-FF Pre-PAS Screening Tool Ages 6 Through 11 Years 09/01/2006 38kbs
DD-099-D-FF Pre-PAS Screening Tool Ages 12 and Older 09/01/2006 38kbs
DD-099-FF Pre-PAS Screening Tol Ages 0 Through 6 Months 09/01/2006 37kbs
DD-162-PD Consent for Use of Behavior-Modifying Medications with a Behavior Treatment Plan 06/01/2006 32KBS
DD-191-FF Incident Report 05/01/2014 76 KB
DD-208-FF Community Living Services (CLS) Application and Agreement 04/01/2012 116 KB
DD-208-FFS Solicitud y Convenio para los Servicios para la Vida en Comunidad (CLS por sus siglas en inglés) 04/01/2012 131 KB
DD-211-FF Home Modifications Services Request 09/01/2014 71 KB
DD-224-FF Changes in the ISP 01/01/2014 53 KB
DD-224-FFS Cambios en el Plan ISP 01/01/2014 55 KB
DD-254 Fire Risk profile 07/01/2003 179KBS 74KBS
DD-301-FF Augmentative Communication Assessment Referral Checklist 08/01/2013 61 KB
DD-308 Individual Emergency Information - Residential 12/01/2004 45KBS 88KBS
DD-390 ISP Strategy 09/01/2011 38 KB
DD-390-A Data Record 04/01/1997 36KBS
DD-403 Reference Request 12/01/2005 29KBS 61KBS
DD-403 S Reference Request (Spanish) 12/01/2005 29KBS 69KBS
DD-417-1 Behavior Modifying Medication Review (Page 1) 08/01/2006 17KBS
DD-417-2 Behavior Modifying Medication Review (Page 2) 08/01/2006 8KBS
DD-417-3 Behavior Modifying Medication Review (Page 3) 08/01/2006 12KBS
DD-522-FF DDD Intake Record 08/01/2010 45kbs
DD-524-FF Authorization for Release of Information 02/01/2012 47 KB
DD-524-FFS Autorización para Entregar Información 02/01/2012 52 KB
DD-525 S Intake Application - 3 Years and Older (Spanish) 06/01/2007 492KBS 291KBS
DD-640 Eligibility 05/01/2015 103 KB
DD-640-S Elegibilidad 05/01/2015 90 KB
DDD Billing DDD Billing Document Template 09/02/2009 732kbs
DDD-1006A Resignation Notice 08/01/1998 9KBS
DDD-1054A Notice Of Inspection Rights-Disclosure Verification 01/01/1999 22KBS
DDD-1056A-S Declaración de Entendemiento del Solicitante para Hogar de Desarrollo para Niño o Adulto 04/01/2015 77 KB
DDD-1088A Client Services Trust Fund 05/01/2008 176KBS
DDD-1088A Client Services Trust Fund (Spanish) 05/01/2008 177KBS
DDD-1151A Communication Skills Questionnaire 03/01/2015 242 KB
DDD-1164A Attendant Care Progress Notes 02/01/2007 18KBS
DDD-1215A Adaptation Station 07/01/2013 403 KB
DDD-1215AS La Estación para Adaptaciones 07/01/2013 399 KB
DDD-1257A Discharge/Transition Checklist 12/01/2005 2024KBS 54KBS
DDD-1258A Emergency Contact Plan 02/01/2006 218KBS 68KBS
DDD-1270A ISP Checklist 05/01/2007 213KBS 61KBS
DDD-1270A S ISP Checklist (Spanish) 05/01/2007 155KBS 66KBS
DDD-1271A Continuation Page 12/01/2005 239KBS 31KBS
DDD-1271A S Continuation Page (Spanish) 12/01/2005 188KBS 34KBS