Form Ddd 1426Aforpf PDF Details

The process of obtaining essential supplies for individuals with developmental disabilities can be intricate, yet it is crucial for ensuring their well-being and dignity. The DDD-1426AFORPF form serves as a vital tool in this process, specifically designed by the Arizona Department of Economic Security's Division of Developmental Disabilities to help individuals aged 3-21 access necessary diaper and brief supplies. This form not only facilitates a streamlined request of diapers or briefs but also underscores the commitment of the department to cater to the health and hygiene needs of these individuals. It meticulously collects member information, including the individual's name, date of birth, AHCCCS ID number, and contact details, ensuring a personalized approach to each request. The attachment of a primary care provider's script, along with a disability diagnosis and a specified need date from the Individual Support Plan (ISP), emphasizes the form's comprehensive nature in addressing incontinence issues. The effort to accommodate a variety of sizes and types of diapers and briefs illustrates an understanding of the diverse needs within this age group. Additionally, the form serves as a reminder of the department's adherence to various civil rights acts and the Americans with Disabilities Act of 1990, ensuring that no individual is discriminated against and that reasonable accommodations are made for those with disabilities. Furthermore, the process for submission, whether through fax, mail, or interoffice delivery, highlights the form's accessibility to those seeking assistance.

QuestionAnswer
Form NameForm Ddd 1426Aforpf
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names795M, DDD-1426AFORFF, ddd forms, 1975

Form Preview Example

DDD-1426AFORPF (3-07)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities (DDD)

DIAPER/BRIEF REQUEST FOR CONSUMERS AGES 3-21

(Indian Health Service and Fee for Service only)

MEMBER INFORMATION

INDIVIDUAL’S NAME

DATE OF BIRTH

AHCCCS ID NO.

DATE

 

 

 

 

 

 

 

HOME ADDRESS (No., Street, City, State, ZIP)

 

 

 

PHONE NO. (Include area code)

 

 

 

 

 

 

 

DIAGNOSIS

HEIGHT

 

WEIGHT

 

WAIST

 

 

 

 

 

 

RESPONSIBLE PERSON’S NAME

 

 

 

PHONE NO. (Include area code)

 

 

 

 

 

 

 

SHIPPING ADDRESS (Cannot ship to a PO Box)

 

 

 

 

 

 

ATTACHED TO THE REQUEST:

Diaper/Brief order form (Page 2)

Disability diagnosis resulting in incontinence

Primary Care Provider (PCP) script

Need date as specified on the Individual Support Plan (ISP)

SUPPORT COORDINATOR’S NAME

PHONE NO. (Include area code)

FAX NO. (Include area code)

SUPPORT COORDINATOR’S SIGNATURE

DATE

HEALTH CARE SERVICES PRIOR AUTHORIZATION UNIT USE ONLY

PROVIDER

AUTHORIZATION NO.

EXPIRATION DATE

Send completed form to:

FAX: Health Care Service Prior Authorization Unit 602-253-9083

Interoffice: Division of Developmental Disabilities

Health Care Services

Site Code 795M

Mail: Division of Developmental Disabilities

Health Care Services, Site Code 795M

2200 North Central Ave., Suite 506

Phoenix, AZ 85004

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964, 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 the Division of Developmental Disabilities ADA Coordinator at (602) 542-6825; TTY/TDD Services: 7-1-1.

DDD-1426AFORFF (3-07) Page 2 of 2

INDIVIDUAL’S NAME

DATE OF BIRTH

AHCCCS ID NO.

DATE

Number of diapers used per day.

Choose one type and the number of cases needed.

Diaper, Pamper Baby Dry (10 lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (8-14 lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (12-18 lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (16-28 lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (22-37 lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (27+ lbs.) 240/Cs

# of cases

Diaper, Pamper Baby Dry (35+ lbs.) 240/Cs

# of cases

Pull-Up, Goodnights - Small/Medium - Boys (40-75 lbs.) 68/Cs

# of cases

Pull-Up, Goodnights - Small/Medium - Girls (40-75 lbs.) 68/Cs

# of cases

Pull-Up, Goodnights - Large/XLarge - Boys (70-125 lbs.) 56/Cs

# of cases

Pull-Up, Goodnights - Large/XLarge - Girls (70-125 lbs.) 56/Cs

# of cases

Pull-Up, All Nights - Medium (45-65 lbs.) 68/Cs

# of cases

Pull-Up, All Nights - Large/XLarge (65-85 lbs.) 56/Cs

# of cases

Pull-Up, Protect - Small (20-28 inch waist) 88/Cs

# of cases

Pull-Up, Protect - Medium (28-40 inch waist) 80/Cs

# of cases

Pull-Up, Protect - Large (40-56 inch waist) 72/Cs

# of cases

Tab Type

 

Briefs, Youth full fit (15-22 inch waist) 96/Cs

# of cases

Briefs, Small Stay Dry (20-31 inch waist) 96/Cs

# of cases

Briefs, Small Molicare (20-30 inch waist) 120/Cs

# of cases

Briefs, Medium Nu-Fit (32-44 inch waist) 96/Cs

# of cases

Briefs, Medium Molicare (27-50 inch waist) 120/Cs

# of cases

Briefs, Large Nu-Fit (45-58 inch waist) 72/Cs

# of cases

Briefs, Large Molicare (43-64 inch waist) 120/Cs

# of cases

Briefs, XLarge Nu-Fit (45-58 inch waist) 60/Cs

# of cases

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1. While completing the ddd forms, ensure to include all important blanks in the relevant form section. It will help expedite the work, making it possible for your information to be processed fast and appropriately.

Stage # 1 in submitting PCP

2. Given that the previous array of fields is complete, you have to insert the needed details in INDIVIDUALS NAME, Number of diapers used per day, DATE OF BIRTH, AHCCCS ID NO, DATE, Diaper Pamper Baby Dry lbs Cs, Diaper Pamper Baby Dry lbs Cs of, Diaper Pamper Baby Dry lbs Cs of, Diaper Pamper Baby Dry lbs Cs of, Diaper Pamper Baby Dry lbs Cs of, Diaper Pamper Baby Dry lbs Cs, Diaper Pamper Baby Dry lbs Cs, PullUp Goodnights SmallMedium, and PullUp Goodnights SmallMedium so you're able to go further.

Completing section 2 of PCP

A lot of people often make some errors while filling in PullUp Goodnights SmallMedium in this section. You should definitely review everything you type in right here.

3. Completing PullUp Goodnights SmallMedium, PullUp Goodnights LargeXLarge, PullUp Goodnights LargeXLarge, PullUp All Nights Medium lbs Cs, PullUp All Nights LargeXLarge, PullUp Protect Small inch waist, PullUp Protect Medium inch waist, PullUp Protect Large inch waist, Tab Type, Briefs Youth full fit inch waist, Briefs Small Stay Dry inch waist, Briefs Small Molicare inch waist, and Briefs Medium NuFit inch waist Cs is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

PullUp All Nights  LargeXLarge, Briefs Medium NuFit  inch waist Cs, and Briefs Small Molicare  inch waist in PCP

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PCP writing process detailed (step 4)

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