Ariz. Admin. Code § R9-20-203 - Application and Renewal

A. An applicant applying to become a provider shall submit to the Department an application packet that contains:

1. An application in a format provided by the Department that includes:

a. The applicant's name;

b. The applicant's mailing address and telephone number;

c. The applicant's email address;

d. The name, telephone number, and email address of the individual acting on behalf of the applicant according to R9-20-202, if applicable;

e. The name under which the applicant plans to do business, if different from the applicant's name;

f. The name of each referring court;

g. The address and telephone number for each facility where treatment is provided; and

h. The applicant's signature and the date signed;

2. A copy of the:

a. Program description required in R9-20-208(A)(1) ,

b. Policies and procedures required in R9-20-208(B), and

c. Policies and procedures required in R9-20-208(D);

3. The name and qualifications of the administrator; and

4. A copy of the applicant's:

a. U.S. Passport, current or expired;

b. Birth certificate;

c. Naturalization documents; or

d. Documentation of legal resident alien status.

B. For renewal, at least 60 days before the expiration of approval, a provider shall submit to the Department in a Department-provided format:

1. The provider's approval number,

2. The information in subsection (A)(1), and

3. The documentation in subsection (A)(2).

Notes

Ariz. Admin. Code § R9-20-203

New Section made by exempt rulemaking at 7 A.A.R. 4439, effective October 3, 2001 (Supp. 01-3). Amended by exempt rulemaking at 9 A.A.R. 3214, effective June 30, 2003 (Supp. 03-2). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2367, effective October 1, 2013 (Supp. 13-2). Amended by final expedited rulemaking at 29 A.A.R. 3435, effective 10/4/2023.