Form Ddd-1790a Forff - Withdraw Hcbs Certification
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1790A FORFF (4-17)
DATE REC’D BY
Division of Developmental Disabilities
DES/DDD OLCR:
Office of Licensing, Certification and Regulation (OLCR)
Home and Community Based Services (HCBS)
LOGIN DATE:
WITHDRAW HCBS CERTIFICATION
LOGIN BY:
INSTRUCTIONS: Please complete the required information. Check the appropriate box below and indicate the reason for
your decision to withdraw/discontinue HCBS certification in the spaces provided.
APPLICANT INFORMATION
FEIN/SSN (Tax ID Number)
AHCCCS ID Number
Applicant’s Name (Last, First, M.I.) / OR Agency Name
Agency Primary Contact Person’s Name (First, Last) – If applicable
Mailing Address (No., Street, P.O. Box)
City
State
ZIP Code
Day/Business Phone Number
Evening/Emergency Phone Number
PLEASE CHECK ONE
I wish to voluntarily withdraw my initial application for HCBS certification.
I wish to terminate my certification to provide home and community based services.
I wish to notify the DES/DDD of my intent not to renew my HCBS certification.
I WISH TO END HCBS CERTIFICATION FOR THE FOLLOWING REASON (Please check one)
Moved out of state (T33/MOVE)
No longer interested in providing services (T34/VOL)
Agency ownership change (T51/OWNER)
Retired (T55/RETIR)
Out of business/closed (T56/OOB)
Other (T30/OTH) (Specify reason)
Applicant/Agency Representative Signature
Requested Date of Withdrawal
Please return this form to: (To be completed by DES DDD OLCR)
HCBS District Representative’s Name (Print Name)
Phone Number
Address (No., Street, P.O. Box)
City
State
ZIP Code
FOR DES DDD OLCR STAFF USE ONLY
Failure to recertify (T28/FAIL)
Rescind withdrawal submitted on:
Death (T32/DEATH)
End date of previous certificate:
Moved out of state (T33/MOVE)
Effective date of new certificate:
Multiple AHCCCS ID (T35/MULTI)
Provider type change (T52/PRCHG)
Returned Mail (T54/MAIL)
DES termination (T58/DES)
Other (T30/OTH)
DES DDD OLCR Signature
Effective Date of Withdrawal
DES DDD District Representative’s Name (Print Name)
Date Processed
Address (No., Street, P.O. Box)
City
State
ZIP Code
Phone Number
Mail Drop Code
See reverse for EOE/ADA/LEP/GINA disclosures
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