R6-6-1504.03. Contents of a Complete Application Package - Initial Certificate

An initial application package is complete when the Division has all of the following information: 1. From the applicant, a completed application form as prescribed in R6-6-1504 (B); and 2. From the applicant, the following documents listed on the application form: a. A completed AHCCCS provider participation agreement form as prescribed in R6-6-1503 which contains the following information: i. The applicant’s name, social security number or tax identification number, and business address; ii. Terms of the agreement between the provider and AHCCCS; and iii. Signature of the applicant. b. A completed declaration of criminal history as prescribed in R6-6-1504(B)(6) on a Division form which contains the following information: i. Name of the applicant, ii. Social security number, iii. Date of birth, iv. Applicant address, v. A declaration of whether or not the applicant has committed any of the crimes listed in R6-6- 1514, and vi. Dated signature. c. Documentation showing that fingerprints have been taken as prescribed in R6-6-1506; d. Documentation showing current CPR training as prescribed in R6-6-1520; e. Documentation showing current First Aid training as prescribed in R6-6-1520; f. Documentation showing Article 9 review as prescribed in R6-6-1520; g. Documentation showing that the applicant has a current driver’s license, vehicle registration, and liability insurance as prescribed in R6-6-1520(D); h. Copies of any applicable professional license or certification as prescribed in R6-6-1504(C); and i. AHCCCS provider registration form as prescribed in R6-6-1503 which contains the following information: i. Name, social security number, and Federal Employer Identification (FEI) number of the applicant; ii. Physical and mailing address of the applicant; iii. Telephone number and telefacsimile number, if applicable for the applicant; iv. Categories of service provided; v. Changes from the prior year, if necessary; vi. AHCCCS provider identification number; vii. Districts and counties served; viii. Place and date of birth; and ix. Dated signature. 3. From sources other than the applicant, the documents listed on the application form as follows: a. Three letters of reference as prescribed in R6-6- 1504(D), and b. Documentation showing that the applicant’s home or office has passed: i. A fire inspection as prescribed in R6-6-1505, and ii. A health and safety inspection as prescribed in R6-6-1505.