Adhs/dbhs Policy Form 1101.1 - Certification Of Need (Con) For Inpatient Facilities Form - Arizona Department Of Health Services

Download a blank fillable Adhs/dbhs Policy Form 1101.1 - Certification Of Need (Con) For Inpatient Facilities Form - Arizona Department Of Health Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Adhs/dbhs Policy Form 1101.1 - Certification Of Need (Con) For Inpatient Facilities Form - Arizona Department Of Health Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Certification of Need (CON) for Inpatient Facilities
A CON must be completed:
Prior to a planned admission (indicate proposed placement) or upon request for authorization; or
For an emergency admission, within 72 hours; or
If an individual applies for AHCCCS assistance while in the hospital, before AHCCCS funding is authorized.
Date of CON*: ______________
Time: ___________
AM
PM
Type of Service Requested:
Psychiatric Acute Hospital
Residential Treatment Center
Crisis BH
Detox
Client Information:
Name: _______________________________________Date of Birth: ________________________
Address: ____________________________________________________________________________________
AHCCCS Number: _____________________
Social Security Number: _____________________
Medical Provider: ______________________
Provider Phone #: __________________________
DSM or ICD Diagnostic Codes:
Axis I: __________ Axis II: __________ Axis III: __________ AXIS IV: __________ AXIS V: __________
• Please indicate why proper treatment of the person’s behavioral health condition requires services on
an inpatient basis under the direction of a physician.
• Please indicate why the requested service can reasonably be expected to improve the person’s
condition or prevent further regression so this level of service will no longer be needed.
• Please indicate why outpatient resources available in the community do not meet the treatment needs
of this person.
I am aware of the client’s condition and have been provided sufficient information to determine this level of
care is appropriate.
Physician’s Signature: ______________________________________ Dated: _____________________
Print Name: ____________________________________________________________
Proposed Placement: _________________________________________________________________________
Inpatient Facility Provider Name: ________________________________________________________________
Requested Date of Admission: _________________________________________________________________
Requested Service Dates:
From: __________ To: __________ Discharge: __________
Providers - completed CON must be faxed to Mercy Maricopa at 855.825.3165
Certification of Need (CON)
Last Effective Date: 02/05/14
ADHS/DBHS Policy Form 1101.1
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Certificate Of Eligibility - Division Of Policy And Shortage Designation Bureau Of Health Workforce, Health Resources Services Administration Certificate Of Eligibility - Division Of Policy And Shortage Designation Bureau Of Health Workforce, Health Resources Services Administration Business
Form Cfn 552-0755 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - Iowa Department Of Administrative Services Form Cfn 552-0755 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - Iowa Department Of Administrative Services Business
Form Fqa-063 - Microbiology Submission - Arizona Department Of Health Services Form Fqa-063 - Microbiology Submission - Arizona Department Of Health Services Legal
Health And Nutrition Services Entity Data Form - Arizona Department Of Education Health And Nutrition Services Entity Data Form - Arizona Department Of Education Legal
Arizona L&d Policyholder And Certificate Census Form - Arizona Department Of Insurance - 2003 Arizona L&d Policyholder And Certificate Census Form - Arizona Department Of Insurance - 2003 Legal
Arizona Form 819nr - Nonresident Distributor's Monthly Return Of Cigars And Tobacco Products Sold (for Nonresident Licensed Distributors) - Arizona Department Of Revenue Arizona Form 819nr - Nonresident Distributor's Monthly Return Of Cigars And Tobacco Products Sold (for Nonresident Licensed Distributors) - Arizona Department Of Revenue Financial
Form F-01164 - Forwardhealth Sterilization Consent Form - Department Of Health Services - 2006 Form F-01164 - Forwardhealth Sterilization Consent Form - Department Of Health Services - 2006 Legal
Form F-11066 - Forwardhealth Prior Authorization/oxygen Attachment (pa/oa) - Wisconsin, Department Of Health Services Form F-11066 - Forwardhealth Prior Authorization/oxygen Attachment (pa/oa) - Wisconsin, Department Of Health Services Legal
Form 5005 - Prime Contractor's Certificate Form - Arizona Department Of Revenue Form 5005 - Prime Contractor's Certificate Form - Arizona Department Of Revenue Business
Arizona Form 800nr - Cigarette Distributor's Monthly Return For Nonresident Licensed Distributors - Arizona Department Of Revenue Arizona Form 800nr - Cigarette Distributor's Monthly Return For Nonresident Licensed Distributors - Arizona Department Of Revenue Financial

Related Categories

Parent category: Legal
Download
Go