Victim Conditions Yes No Has the patient complied with ALL victim conditions outlined ? Return via Email by the 5th of the month to Jaime.shapiro@azhs.gov No Medicalmanagement@azahcccs.gov Name of Person Completing Report: Title of Person Completing Report: Name of
Victim Conditions Yes No Has the patient complied with ALL victim conditions outlined ? Return via Email by the 5th of the month to Jaime.shapiro@azhs.gov No Medicalmanagement@azahcccs.gov Name of Person Completing Report: Title of Person Completing Report: Name of