Ddd-1432a forlp (6-10) arizona department of




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DDD-1432A FORLP (6-10)







ARIZONA DEPARTMENT OF
ECONOMIC SECURITY



Division of Developmental Disabilities


     

Telephone:      

Fax:      




TTY/Voice Services: 7-1-1





CRITICAL SERVICE GAP REPORT
All ALTCS members have the right to receive all critical services in their Individual Support Plan / Individualized Family Support Plan to help with bathing, dressing, toileting, feeding, transferring to or from your bed or wheelchair and other similar daily activities. If you do not receive your critical services as specified in your Individual Support Plan / Individualized Family Support Plan, you should report this as quickly as possible. You should immediately call the AHCCCS, provider agency or contractor at the phone numbers listed on the Contingency Plan form your support coordinator filled out with you. You may also call your support coordinator. You have the right to receive these critical services from a back-up

DDD-1432A FORLP (6-10)








substitute caregiver within 2 hours of you reporting the gap.
In addition, you can mail this form to us at the address listed above telling us the services you have not received. Someone from the Division will respond to you either by telephone or mail. You will be told the reason for the delay and what is being done to ensure this does not happen again. Please complete the following:

Name of person completing this form:

     




Phone Number:

     




Date Completed:

     




Members Name:

     




AHCCCS ID Number:

     




and/or Date of Birth:

     



DDD-1432A FORLP (6-10)










Date(s) member did not receive authorized services:




     




     




     




     




     




     



Authorized service(s) not received:

     




Name of Provider who did not provide authorized service(s):

     




Support Coordinator:

     




Comments:

     

DDD-1432A FORLP (6-10)








FOR DIVISION USE ONLY


Date Received

     

Date of Response

     



Check Response Type:
 By mail

 By telephone



 In person


Equal Opportunity Employer/Program  Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact 602-542-0419; TTY/TDD Services: 7-1-1.  Free language assistance for DES services is available upon request.  Disponible en español en línea o en la oficina local.


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