REPORT ID:
RP92M401 ARIZONA
HEALTH CARE COST CONTAINMENT SYSTEM PAGE: 1
PROGRAM #:
RP92L400 MHS
MONTHLY TERMINATIONS RUN:
12/29/03
AS
OF 12/29/03 16:27
FOR RBHA 03 YUMA BEHAVIORAL
HEALTH SERVICE
AGE ELG-ENRL CTY CHG ACUTE CTRT MHS BHS
AHCCCS ID DOB ON 1ST ON 1ST ON 1ST ACTION RSN HP-ID BEGIN
END TYP CAT SITE
_________ __________ ______ _________________ ______ _________________ ___ ______ ________ ________ ____ ___ ____
A99999999 09/21/1971 32 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 07/25/03 12/31/03 A G 03
A99999999 01/11/1991 12 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 02/25/03 12/31/03 A C 03
A99999999 10/27/1984 19 NO ELIGIBILITY
27 TERMINATE FYI
REC IE 010158 07/25/03 12/31/03 A G 03
A99999999 12/20/1970 33 NO ELIGIBILITY 29 TERMINATE FYI
REC IE 010158 09/29/03 12/31/03 A G 03
A99999999 11/15/1989 14 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010306 12/01/02 12/31/03 A Z 03
A99999999 01/13/1990 13 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 01/23/03 12/31/03 A C 03
A99999999 02/14/1984 19 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 10/28/03 12/31/03 A G 03
A99999999 09/25/1991 12 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 10/24/03 12/31/03 A C 03
A99999999 09/23/1991 12 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 06/01/03 12/31/03 A C 03
A99999999 01/09/1990 13 NO ELIGIBILITY 29 TERMINATE FYI
REC IE 010158 07/01/03 12/31/03 Y C 03
A99999999 11/06/1953 50 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 02/07/03 12/31/03 A G 03
A99999999 05/02/1971 32 NO ELIGIBILITY 27 TERMINATE FYI
REC IE 010158 09/23/02 12/31/03 A S 03