AZ DE-121 2008-2024 free printable template

If NO complete all pages of this form. DE-121 Rev. 1/08 PART I INFORMATION ABOUT MEDICAL RECORDS 1. 1. Signature of Witness Address number and street city state and zip code PART VII FOR AHCCCS USE ONLY DO NOT WRITE BELOW THIS LINE DE-121 Taken by Personal Interview Telephone Form Supplemented YES NO If YES by Mail Signature of Eligibility Specialist Local Office Address Local Office Phone Number. AHCCCS is Arizona s Medical Assistance Program Medicaid ARIZONA HEALTH CARE COST...

Please keep confidential any information given to an attorney, counselor, clerk, employer, or any other person acting on behalf of the applicant, including but not limited to: Names, Social Security numbers, addresses, etc. A copy of the Social Security card or a copy of the person s ID or other government issued ID (a driver's license, passport, etc.) does not disqualify an applicant under the Act. All information furnished to an attorney, counselor, assistant counsel, or clerk or any other person acting on behalf of the applicant will be used solely for purposes of the investigation of the applicant or as required by law or as otherwise required by law. If any information furnished to an attorney, counselor, assistant counsel, clerk, employer, or any other person acting on behalf of the applicant is incorrect or cannot be verified, you must correct the error and the information you provide will not be used for any purpose that may jeopardize the proper administration of Medicaid. Answers to questions will not be given via e-mail or any other form of electronic communication, but you may send them to the e-mail address supplied. Please do not mail them. Please do not fax them. Incomplete answers or other problems will not be corrected. If a question contains incorrect information, or a response is not appropriate for purposes outlined in the Act, the appropriate answer is to complete the Question to Clarify the Response field or, if appropriate, the Field to Select from the responses field. If you have any questions about the Medicaid eligibility rules, please call the Arizona Health Care Cost Containment System (AHC CCS) or visit the following website : AHC CCS Public Assistance, Social Services and Benefits Division State of Arizona Phone:; Toll-Free: TTY: AHC CCS Contact: CARE — Arizona Health Care Cost Containment PO BOX 392035 — AHC CCS Phoenix, AZ 85006 or FAX: E-mail: infoaichccs.

People Also Ask about de 121

What is the billing code for Ahcccs transportation?

Code A0888 may only be billed for AHCCCS members who also are covered by Medicare. Services must be medically necessary. Claims for ground and air ambulance service must be billed on the CMS 1500 claim form. Emergency transportation does not require prior authorization.

How do I start a non emergency medical transportation in Arizona?

How to start an NEMT business Step 1: Legally form your NEMT business. Step 2: Gather licensing and insurance. Step 3: Get the necessary transport equipment. Step 4: Hire NEMT employees. Step 5: Market your NEMT business. Step 6: Optimize driver schedules and routes.

Does Ahcccs help with transportation?

AHCCCS covers medically necessary non-emergency ground and air transportation to and from a required medical service for most recipients. Non-emergency transportation is not covered for Federal Emergency Services (FES) Members.

Does Ahcccs cover non-emergency transportation?

AHCCCS covers medically necessary non-emergency ground ambulance and air transportation to and from a required, covered medical service for most recipients.

How to start a non medical transportation business in Arizona?

How to start an NEMT business Step 1: Legally form your NEMT business. Step 2: Gather licensing and insurance. Step 3: Get the necessary transport equipment. Step 4: Hire NEMT employees. Step 5: Market your NEMT business. Step 6: Optimize driver schedules and routes.

Does AHCCCS cover non emergency transportation?

AHCCCS covers medically necessary non-emergency ground ambulance and air transportation to and from a required, covered medical service for most recipients.

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What is mileage form ahcccs?

The mileage form for AHCCCS refers to a document that is used to claim transportation expenses for medical appointments and services covered by the Arizona Health Care Cost Containment System (AHCCCS), which is Arizona's Medicaid program. This form allows AHCCCS members to request reimbursement for mileage expenses incurred while traveling to and from medical appointments, including doctor visits, specialist consultations, hospital visits, and other health-related services. It requires the member to record the date, destination, purpose of the trip, and the number of miles traveled. This form enables AHCCCS to provide financial assistance to its beneficiaries for transportation costs associated with receiving necessary medical care.

Who is required to file mileage form ahcccs?

AHCCCS is the Arizona Health Care Cost Containment System, which is the Medicaid program in Arizona. The organization primarily provides healthcare coverage for low-income individuals and families. As for mileage reimbursement forms, they are typically required to be filed by AHCCCS members who have received approval for transportation services through the program. These members may include individuals who need transportation to medical appointments, treatments, or other healthcare-related services. It is important to verify the specific requirements and guidelines outlined by AHCCCS regarding mileage reimbursement forms.

How to fill out mileage form ahcccs?

To fill out the mileage form for AHCCCS (Arizona Health Care Cost Containment System), please follow the steps below: 1. Obtain the mileage form: You can download the AHCCCS mileage form from their official website or request a copy from your AHCCCS case manager. 2. Personal Information: Fill in your personal details at the top of the form. This typically includes your full name, AHCCCS identification number, contact information, and date of travel. 3. Travel Information: Provide the specific details of your travel. This includes the date(s) of the trip, starting and ending locations, and purpose of travel (medical appointment, pharmacy visit, etc.). 4. Mileage Calculation: Record the starting and ending mileage of your vehicle for each trip. If your vehicle has an odometer, you can use the difference between the two readings. Otherwise, you can use online mapping tools (such as Google Maps) to calculate the distance between locations. 5. Total Mileage: Sum up the mileage for all trips taken during the specified dates and enter the total in the appropriate section. 6. Certification and Signature: Read the certification statement at the bottom of the form. By signing, you certify that the information provided is accurate and that you understand any penalties for providing false information. 7. Supporting Documents: Check if any supporting documentation is required to accompany the mileage form, such as appointment confirmation letters, invoices, receipts, or transportation logbooks. Ensure you attach any necessary proof. 8. Submission: After completing the form and attaching any supporting documents, submit the form by mailing or delivering it to the designated AHCCCS office or case manager. Alternatively, you may be able to submit it electronically, depending on AHCCCS' guidelines. Remember to retain a copy of the completed form and any supporting documents for your records.

What is the purpose of mileage form ahcccs?

The purpose of the mileage form for AHCCCS (Arizona Health Care Cost Containment System) is to track and reimburse individuals for the eligible transportation expenses incurred when traveling to receive medical services. AHCCCS is a state-based Medicaid program that provides health insurance to eligible low-income individuals and families in Arizona. The mileage form allows individuals to claim reimbursement for the mileage traveled to healthcare appointments, typically at a specified rate per mile, to help cover the cost of transportation.

What information must be reported on mileage form ahcccs?

The following information is typically required to be reported on a mileage form for AHCCCS (Arizona Health Care Cost Containment System): 1. Date of travel: The specific date on which the mileage was traveled should be mentioned. 2. Starting location: The address or name of the place where the journey began. 3. Destination: The address or name of the place where the journey ended. 4. Purpose of travel: The reason for the mileage, such as medical appointment, pharmacy visit, or other authorized medical-related trips. 5. Total miles traveled: The total number of miles driven for the trip should be recorded. 6. Vehicle information: The make and model of the vehicle used for travel should be mentioned. 7. Name and signature: The person who completed the travel and is claiming the mileage reimbursement should provide their name and signature. 8. Provider information: If the travel was related to a specific medical provider, their name and any necessary information should be recorded. It's important to note that these requirements may vary slightly depending on the specific guidelines provided by AHCCCS. Checking with AHCCCS or referring to their official mileage reimbursement policy can provide more accurate and up-to-date information.

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