Form Ddd-1426aforpf - Diaper/brief Request For Consumers Ages 3-21 (Indian Health Service And Fee For Service Only)
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2DDD-1426AFORPF (3-07)
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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities (DDD)
DIAPER/BRIEF REQUEST FOR CONSUMERS AGES 3-21
(Indian Health Service and Fee for Service only)
MEMBER INFORMATION
INDIVIDUAL’S NAME
DATE OF BIRTH
AHCCCS ID NO.
DATE
HOME ADDRESS (No., Street, City, State, ZIP)
PHONE NO. (Include area code)
DIAGNOSIS
HEIGHT
WEIGHT
WAIST
RESPONSIBLE PERSON’S NAME
PHONE NO. (Include area code)
SHIPPING ADDRESS (Cannot ship to a PO Box)
ATTACHED TO THE REQUEST:
Diaper/Brief order form (Page 2)
Primary Care Provider (PCP) script
Disability diagnosis resulting in incontinence
Need date as specified on the Individual Support Plan (ISP)
SUPPORT COORDINATOR’S NAME
PHONE NO. (Include area code)
FAX NO. (Include area code)
SUPPORT COORDINATOR’S SIGNATURE
DATE
HEALTH CARE SERVICES PRIOR AUTHORIZATION UNIT USE ONLY
PROVIDER
AUTHORIZATION NO.
EXPIRATION DATE
Send completed form to:
FAX:
Health Care Service Prior Authorization Unit
602-253-9083
Interoffice:
Division of Developmental Disabilities
Health Care Services
Site Code 795M
Mail:
Division of Developmental Disabilities
Health Care Services, Site Code 795M
2200 North Central Ave., Suite 506
Phoenix, AZ 85004
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964, and the Americans with Disabilities
Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits
discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
and disability. 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 the Division of Developmental Disabilities ADA Coordinator at (602) 542-6825; TTY/TDD Services: 7-1-1.
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