Member Name AKA Telephone AHCCCS ID # DOB Male Female □ □ Rate Code & # Relinquishing Contractor /RBHA Receiving Contractor/RBHA Medicare Part A Part B Other Insurance Plan ID # □ □ ALTCS Application Pending Yes No Date □ □ Diagnosis Secondary Diagnosis PCP Name Telephone High Risk Yes No Explain Risk □ □ Pregnancy EDC Maternity Provider Telephone Special Medications Injectable Yes No □ □ Transplant Yes No Type Date Facility □ □ Catastrophic Reinsurance Yes No Diagnosis □ □ Specialist Name Type Telephone Out-of-Area-Appt Yes No Provider Telephone □ □ Outpatient Services Yes No Provider Telephone □ □ Outpatient PT Yes No # of Visits in Current Contract Year □ □ Home Health Yes No Provider Telephone □ □ Home Health Services Case Management Yes No Please Explain □ □ Case Manager Name Telephone Inpatient Yes No Facility Name Telephone □ □ SNF Yes No Facility Name Telephone □ □ # of SNF Days used/benefit year Residential Yes No Facility Name Telephone □ □ Admitting Diagnosis Admission Date ALTCS Dental Benefit Used ($) Expected Discharge Date CRS Diagnosis(s) Behavioral Health Yes No Provider Telephone □ □ COT Yes No Court of Jurisdiction Special Assistance (SMI) Yes No Contact Name & Relation: Telephone: □ □ Guardian Yes No Name Telephone □ □ Respite Hrs Used DME Vendor Telephone Date Type of DME Equipment Telephone Medical Foods Yes No Vendor Own Rent □ □ □ □ Other Care Needs Non-Emergency Medical Transportation Yes No Mode □ □
Member Name AKA Telephone AHCCCS ID # DOB Male □ Female □ Rate Code & # Relinquishing Contractor /RBHA Receiving Contractor/RBHA Medicare Part A □ Part B □ Other Insurance Plan ID # ALTCS Application Pending Yes □ No □ Date Diagnosis Secondary Diagnosis PCP Name Telephone High Risk Yes □ No □ Explain Risk Pregnancy EDC Maternity Provider Telephone Special Medications Injectable Yes □ No □ Transplant Yes □ No □ Type Date Facility Catastrophic Reinsurance Yes □ No □ Diagnosis Specialist Name Type Telephone Out-of-Area-Appt Yes □ No □ Provider Telephone Outpatient Services Yes □ No □ Provider Telephone Outpatient PT Yes □ No □ # of Visits in Current Contract Year Home Health Yes □ No □ Provider Telephone Home Health Services Case Management Yes □ No □ Please Explain Case Manager Name Telephone Inpatient Yes □ No □ Facility Name Telephone SNF Yes □ No □ Facility Name Telephone # of SNF Days used/benefit year Residential Yes □ No □ Facility Name Telephone Admitting Diagnosis Admission Date ALTCS Dental Benefit Used ($) Expected Discharge Date CRS Diagnosis(s) Behavioral Health Yes □ No □ Provider Telephone COT Yes No Court of Jurisdiction Special Assistance (SMI) Yes □ No □ Contact Name & Relation: Telephone: Guardian Yes □ No □ Name Telephone Respite Hrs Used DME Vendor Telephone Date Type of DME Equipment Telephone Medical Foods Yes □ No □ Vendor Own □ Rent □ Other Care Needs Non-Emergency Medical Transportation Yes □ No □ Mode
AMPM-520-Attachment-A-Enrollment-Transition-Information-ETI-Form.docx