Instructions for Completion of the Children’s Rehabilitative Services Application

The Arizona Health Care Cost Containment System (AHCCCS) Division of Member Services (DMS) Children’s Rehabilitative Services (CRS) Enrollment Unit reviews applications for enrollment into the CRS program. In order to be in the CRS program AHCCCS members must require active treatment for one of the medical conditions defined in A.A.C. R9-22-1303.

If the CRS applicant is not currently in AHCCCS they must enroll either:

•	By calling AHCCCS toll free at 1-800-654-8713;
•	Applying online at www.healthearizonaplus.gov; or
•	Going to https://www.azahcccs.gov/Members/GetCovered/apply.html, printing and completing an AHCCCS application.

How to Apply for the CRS Program

To apply for the CRS program, a CRS application, either in English or Spanish, (click on the highlighted areas below) needs to be filled out and submitted with medical documentation that supports the potential CRS condition to the CRS Enrollment Unit.

•	CRS Application in English
•	CRS Application in Spanish

Anyone can fill out an application including a family member, doctor, or health plan representative. The CRS Enrollment Unit can also assist you with completing the form. You can contact them at: 602-417-4545 or 1-855-333-7828.

Complete the following information on the CRS application:

•	The AHCCCS identification number and the current AHCCCS Health Plan, if you are a current AHCCCS member. If not, indicate if you have applied in section one (1) on the CRS application.
•	First name, middle initial and last name;
•	Date of birth;
•	Gender;
•	Social Security number;
•	Parent/Representative’s name, relationship to the applicant, mailing address, and phone numbers;
•	Primary Care Provider’s name, address and contact information;
•	Primary diagnosis including treatment plan information;
•	Name, address and phone number of the referral source (when someone other than you or a family member completes an application, this is called a referral);
•	State the relationship between the referral source and the applicant; and
•	If you want to authorize AHCCCS to release information to the referral source the consent section at the bottom of the application form must be signed by the parent/representative.

NOTE: You cannot be enrolled in the CRS program until you become an AHCCCS member.

Don’t forget to send the information supporting the medical diagnosis and the need for treatment. You can contact your doctor to help you collect the medical information.
The completed application along with the medical information can be mailed or faxed to: AHCCCS/Children's Rehabilitative Services
Attn: CRS Enrollment Unit 801 East Jefferson MD3500 Phoenix, AZ 85034
Fax: 602-252-5286

CRS Enrollment Unit: 602-417-4545 or 1-855-333-7828
The CRS Enrollment Unit will send you a written notice indicating when your CRS application has been approved or denied.
Updated  2/2016