Form Ddd-1432a - Critical Service Gap Report
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1432AFORFF (6-17)
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 services in their care plan to help with bathing, dress-
ing, toileting, 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 report 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 support coordina-
tor. 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 re-
ceived. As your program contractor, we will respond to you either by telephone or by the mail. You will be told
the reason for the delay and how it will be fixed now and in the future if it happens again. Please fill in the
following:
Your Name:
AHCCCS ID Number (if available):
Date of Birth:
Date(s) you did not receive your service(s):
Authorized service(s) not received:
Critical service(s) not received:
Comments:
FOR DIVISION USE ONLY
Date Received
Date of Response
Check Response Type
By mail
By telephone
In person
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document
in alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at
602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Ayuda gratuita con
traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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