Arizona Department of Economic Security Forms

This form provides an overview of the Empower Program in Arizona and includes an acknowledgment section. It is used to provide information and obtain consent from participants.

This document is for electronic visit verification (EVV) designees in Arizona to attest their responsibilities. EVV is a system used to track and verify home health care services provided to Medicaid recipients.

This form is used for creating a contingency/back-up plan for Electronic Visit Verification (EVV) members in Arizona. It ensures that there is a plan in place to accommodate unforeseen circumstances or technical issues to ensure the continuity of care.

This form is used for electronic visit verification paper timesheet in Arizona.

This form is used for obtaining prior authorization for equipment and supplies under the DDD Tribal Health Program (THP) in Arizona.

This Form is used for applying to have eligibility for services reevaluated when turning 18 years old in Arizona.

This Form is used as the cover page for the Child Developmental Certified Home Application in Arizona.

This form is used for certifying or recertifying the Evaluation Report Plan of Care/Treatment Plan in the state of Arizona.

This form is used for reporting monthly statistics on food distribution in Arizona. It provides instructions and guidelines for completing the Form HRP-1012A.