Form Ddd-1590a Forff - Monthly Invoice Cover Sheet
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1DDD-1590A FORFF (5-17)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities
MONTHLY INVOICE COVER SHEET
FROM
FOUR DIGIT ALPHA CODE
CONTACT PERSON
PROVIDER ID NO.
PHONE NO.
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP
MONTH ENDING
TOTAL AMOUNT BILLED
I certify that the information contained in the attached invoice is correct and is prepared in accordance
with the terms of the contract.
PROVIDER SIGNATURE
DATE
All claims should be submitted to:
Arizona Department of Economic Security
Division of Developmental Disabilities
ATTN: Business Operation Unit – Site 2HC1
P.O. Box 6123
Phoenix, Arizona 85005-6123
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. 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 602-542-0419; 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 está disponible a
solicitud del cliente.
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