Community Service Agency Title Xix Certification Intent To Contract Form

961-107

XHIBIT

RIZONA

EALTH

ARE

OST

ONTAINMENT

YSTEM

COMMUNITY SERVICE AGENCY

TITLE XIX

CERTIFICATIONINTENT TO

CONTRACT FORM

Providers/applicants submitting applications for Community Service Agency

Title XIX

Certificatio

nApproval

will submit applications through one T/RBHA, but may contract with

multiple T/RBHAs to provide CSA services. As such, the following serves as verification that

the provider/applicant either contracts with, or intends to contract with, other T/RBHAs.

has a entered into a contract with

T/RBHA Name Here

Provider/Applicant Name Here

for the provision of behavioral health rehabilitation and/or support services.

Exhibit reviewed with DBHS Policy 404 form(s) and updated to align with revisions to AMPM 961.

Initial Effective Date: 7/01/2016

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Parent category: Legal