Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 14
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15AG-095 (11-14) – Page 14
CLIENT’S NAME
DAARS ID NO.
PART VII: SERVICE ENROLLMENTS
PROVIDER / SUBCONTRACTOR
PROVIDER CODE
OPEN
CHANGE
CLOSE
CONTINUE
SCOPE OF WORK
PROGRAM
SERVICE DETAIL
ENROLLMENT STATUS
CLOSURE REASON
LOCATION (Optional)
Enrolled
Disenrolled
Waitlisted
AUTHORIZATION PERIOD (mm/dd/yy)
COST SHARE AMOUNT PER UNIT/MONTH
COST SHARE OPTION
From:
Through:
Total
Rate
QUANTITY
UNITS
FREQUENCY/PERIOD
One time
Daily
Weekly
Monthly
Other:
COMMENTS
PROVIDER / SUBCONTRACTOR
PROVIDER CODE
OPEN
CHANGE
CLOSE
CONTINUE
SCOPE OF WORK
PROGRAM
SERVICE DETAIL
ENROLLMENT STATUS
CLOSURE REASON
LOCATION (Optional)
Enrolled
Disenrolled
Waitlisted
AUTHORIZATION PERIOD (mm/dd/yy)
COST SHARE AMOUNT PER UNIT/MONTH
COST SHARE OPTION
From:
Through:
Total
Rate
QUANTITY
UNITS
FREQUENCY/PERIOD
One time
Daily
Weekly
Monthly
Other:
COMMENTS
PROVIDER / SUBCONTRACTOR
PROVIDER CODE
OPEN
CHANGE
CLOSE
CONTINUE
SCOPE OF WORK
PROGRAM
SERVICE DETAIL
ENROLLMENT STATUS
CLOSURE REASON
LOCATION (Optional)
Enrolled
Disenrolled
Waitlisted
AUTHORIZATION PERIOD (mm/dd/yy)
COST SHARE AMOUNT PER UNIT/MONTH
COST SHARE OPTION
From:
Through:
Total
Rate
QUANTITY
UNITS
FREQUENCY/PERIOD
One time
Daily
Weekly
Monthly
Other:
COMMENTS
PROVIDER / SUBCONTRACTOR
PROVIDER CODE
OPEN
CHANGE
CLOSE
CONTINUE
SCOPE OF WORK
PROGRAM
SERVICE DETAIL
ENROLLMENT STATUS
CLOSURE REASON
LOCATION (Optional)
Enrolled
Disenrolled
Waitlisted
AUTHORIZATION PERIOD (mm/dd/yy)
COST SHARE AMOUNT PER UNIT/MONTH
COST SHARE OPTION
From:
Through:
Total
Rate
QUANTITY
UNITS
FREQUENCY/PERIOD
One time
Daily
Weekly
Monthly
Other:
COMMENTS
PROVIDER / SUBCONTRACTOR
PROVIDER CODE
OPEN
CHANGE
CLOSE
CONTINUE
SCOPE OF WORK
PROGRAM
SERVICE DETAIL
ENROLLMENT STATUS
CLOSURE REASON
LOCATION (Optional)
Enrolled
Disenrolled
Waitlisted
AUTHORIZATION PERIOD (mm/dd/yy)
COST SHARE AMOUNT PER UNIT/MONTH
COST SHARE OPTION
From:
Through:
Total
Rate
QUANTITY
UNITS
FREQUENCY/PERIOD
One time
Daily
Weekly
Monthly
Other:
COMMENTS
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