Heaplus Community Partner Application

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HEAplus Community Partner Application 
Please complete this application and email it to HEAAHCCCS@azahcccs.gov . Submitting this application does not 
guarantee an acceptance as a community partner organization; we reserve the right to refuse partnership.  
1. Name of your organization: _________________________________________________________ 
2. URL for your organization’s website (if any): _________________________________________ 
3. Briefly provide an explanation of how your organization plans to use the system:  
     ___________________________________________________________________________________________ 
4. Locations: Please enter the name, address and phone number of each location you want to have included in your 
HEAplus account. Note: Only specify the location(s) that will be directly utilizing the HEAplus Application.   
Name of Location 
Address of Location 
Phone Number 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5. Type of Organization (Select one): 
☐AHCCCS Registered Medical Provider or Contractor (RBHA, health plan, FQHC, hospital, other clinic or medical 
     
provider) 
☐Tribal 638, IHS, Urban Indian Health Center or tribal social service office 
 
      
 ☐Non‐Profit Community Organization (church, food bank, social services agency) 
      
 ☐State or Local Government 
      
 ☐Other organization 
 
 
Revised 03/10/2017 

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