|GCI-1074A FORFF (1-14) |Arizona Department of Economic Security | |
| |Arizona Early Intervention Program (AzEIP) | |
| | |DATE |
| | |4/9/2016 |
| |AzEIP AHCCCS Member Service Request | |
|AzEIP SERVICE COORDINATOR’S NAME |PHONE NO. |EMAIL |
|Noelle Franks |480-229-5280 |Noelle.ACT@gmail.com |
|AzEIP TBEIS CONTRACTOR |PHONE NO. |EMAIL |
|Arizona Cooperative Therapies |o-602-547-1111/ |n/a |
| |f-602-938-4362 | |
|TYPE: Initial IFSP | Six Month Review | Annual IFSP | Other/Addendum: |DATE |
| | | | |3/31/2016 |
|Child’s Information |
|CHILD’S NAME |AHCCCS ID NO. |DATE OF BIRTH |EXPECTED MONTH/YEAR OF TRANSITION |
|Corban Young |A94531816 |11/19/2015 |FROM AzEIP |
| | | |11/2018 |
|PARENTS’ / GUARDIANS’ NAME(S) |PREFERRED LANGUAGE |AHCCCS HEALTH PLAN |PRIMARY CARE PHYSICIAN |
|Jenilyn Young |English |Healthnet |De. Winterland |
|MAILING ADDRESS (No., Street, City, State, ZIP) |HOME PHONE NO. |WORK PHONE NO. |CELL / MESSAGE PHONE NO. |
|1319 N. Roca Mesa Azz 85213 |480-330-4325 | | |

SEE ATTACHED: AzEIP Developmental Evaluation Report and Results of the most recent evaluations and assessments.
|Expected outcomes: |
|1. Corban will safely and calmly drink his bottle during mealtime |
|2.Corban will turn his head to the right side and sustain it their for brief periods of time during play and mealtime. |
|Dear Primary Care Physician: The child identified above is eligible for AzEIP and the AzEIP Individualized Family Service Plan (IFSP) Team is recommending the |
|EPSDT services identified below. Please review the documentation, indicate whether each requested service is medically necessary by checking “yes” in shaded box|
|next to each service and return to the health plan MCH coordinator who will coordinate prior authorization for the services you deem medically necessary. If you|
|feel the services are not medically necessary, or the child should not receive these services at this time, please explain below: |
| |
|PRIMARY CARE PHYSICIAN’S SIGNATURE |DATE |
| | |
|To be completed by the AzEIP Service Coordinator: |Completed by PCP |Completed by |
| | |AHCCCS Contractor |
|Requested |Requested Provider and Phone|Planned Start |Frequency |Duration |Medically |AHCCCS Contractor |NOA Sent |
|Services/CPT Code |No. |Date | | |necessary service | | |
| | | | | | Yes No | Approve | Yes |
| | | | | | |Deny |No |
| | | | | | Yes No | Approve | Yes |
| | | | | | |Deny |No |
|If services are not medically necessary, or if the PCP wants to examine the member to determine medical necessity, the AHCCCS Contractor will deny the services |
|and send a Notice of Action (NOA) letter to the member’s parents/guardians and the AzEIP Service Coordinator. |

To be completed by the AHCCCS Contractor:
|The AHCCCS Contractor must document what is approved: provider, frequency, duration and service begin date and service end date. |
| If the Service Provider is unknown, the AHCCCS Contractor will identify a Service Provider below for: PT OT SLP |
|If the requested Service Provider is not approved by the Contractor, the AHCCCS Contractor will identify an approved provider below. |
|Approved Provider |Provider |Approved |Begin |End |Frequency |Duration |
| |Phone No. |Service(s) |Date |Date | | |
| | | | | | | |
| | | | | | | |

See reverse for EOE/ADA/LEP/GINA disclosures

Contacts

|Health Plan: Healthnet Access |
|MCH Coordinator: Cheryl Walton |
|Phone No.: 602-794-1539 |
|Fax No.: 1-866-612-7188 |
|AzEIP Coordinator: Arizona Cooperative Therapies (ACT) |
|Phone No.: 602-547-1111 |
|Fax No.: 602-938-4362 |
|Primary Care Physician: Dr Winterland |
|Phone No.: 480-214-2300 |
|Fax No.: 480-214-2301 |
|Service Provider: Susan Hodges |
|Phone No.: 317-670-9892 |
|Fax No.: |

Additional Information

|Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 |
|(ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) |
|of 2008, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national |
|origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a |
|program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair|
|accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and |
|understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a |
|program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in |
|alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services|
|is available upon request. |
|Note: AHCCCS based form, does not conform to all DES standards |