Form Ddd-1432a - Critical Service Gap Report
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3DDD-1432AFORFF (6-17)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities
CRITICAL SERVICE GAP REPORT
Telephone:
Fax:
TTY/Voice Services: 7-1-1
All ALTCS members have the right to receive all critical ser-
vices in their care plan to help with bathing, dressing, toilet-
ing, feeding, transferring to or from your bed or wheelchair
and other similar daily activities. If you do not receive your
critical services as specified in your care plan, you should re-
port this as quickly as possible. You should immediately call
the AHCCCS, provider agency or contractor at the phone
numbers listed on the Contingency Plan Form your support
coordinator filled out with you. You may also call your sup-
port coordinator. You have the right to receive these critical
services from a back-up substitute caregiver within two hours
of you reporting the gap.
In addition, you can mail this form to us at the address listed
above telling us the services you have not received. As your
program contractor, we will respond to you either by tele-
phone or by the mail. You will be told the reason for the de-
lay and how it will be fixed now and in the future if it happens
again. Please fill in the following:
See last page for EOE/ADA/LEP/GINA disclosures
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