1
Client
2
Evaluation
3
Prelim. Rec.
4
Provider
5
Review
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1
Client
2
Evaluation
3
Prelim. Rec.
4
Provider
5
Review
1
Client
2
Evaluation
3
Prelim. Rec.
4
Provider
5
Review
Packet Submission Contact*
Packet Submission Phone*
Provider contact for packet submission questions.
Packet Submission Email*
Separate multiple email addresses with a semicolon and a space
Clinical Contact*
Clinical Contact Phone*
CRN will contact with individual to clinically staff the application. This should be the individual most familiar with the case. i.e. - BHMP, Case Manager, Treating Prescriber, etc.
Clinical Contact Email
Multiple contacts, phone numbers, and email addresses may be added in these fields. Separate these with a semicolon and a space.
1
Client
2
Evaluation
3
Prelim. Rec.
4
Provider
5
Review
Client Information
Removal of Designation
Region
AHCCCS ID
Current AHCCCS Plan
(T)RBHA Assigned To
First Name
Middle Name
Last Name
Date of Birth
Applicant Phone
Applicant Email
Gender
Preferred Pronoun
Preferred Language
Preferred Communication
Race
Ethnicity
Is the Applicant Currently Experiencing Homelessness?
Determination Type
Evaluation Information
Received Date
Received Time
Consent Signed Date
Consent Signed Time
Evaluation Location
Waiver of 3 Day Determination
Preliminary Recommendation Information
Assessor
Assessor Credentials/Position
Date of Prelim. Rec.
Is Applicant Functionally Impaired?
Is Applicant at Risk of Deterioration?
Non-Qualifying Diagnosis
Applicant Does Not Meet Criteria?
Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5
Provider Information
Provider
Packet Submission Contact
Packet Submission Phone
Packet Submission Email
Clinical Contact
Clinical Phone
Clinical Email