Application For 
AHCCCS Children’s Rehabilitative Services Designation	

The customer must first be enrolled in AHCCCS to begin this process. Complete this application to start the process of determining a CRS designation. For questions contact the CRS Unit at (602) 417-4545 from area codes (480, 602 or 623) or 1 (855) 333-7828 from area codes (520, 760 or 928) toll free. You can return this application and all required documentation by:
	
Mail:
AHCCCS-CRS Unit
801 E Jefferson St MD 3500
Phoenix AZ 85034
	Fax:
(602) 252-5286	E-mail:
dmscrs@azahcccs.gov	
Section 1: Customer Information	
Customer’s First Name:
     	M.I.
     	Customer’s Last Name:
     	
AHCCCS ID (required):
     	AHCCCS Complete Care Plan (required):
     	
Date of Birth:
     	Gender:
 Male	 Female	Customer’s Social Security Number:
     -     -     	
Parent/Representative’s Name:
     	Phone Number:
     	
Relationship to Customer:
 Parent		 Legal Guardian	 Representative	Other:      	
Parent/Representative’s Mailing Address:
     	City:
     	State:
     	ZIP Code:
     	
Section 2: Medical Information	
Name of Customer’s Primary Care Provider:
     	Primary Care Provider’s Phone numbers: 
Office:      		Fax      
	
Name of Customer’s Specialist:
     	Specialist’s Phone numbers:
Office:      		Fax      	
List the diagnosis:      

	
Section 3: Referral Information	
 Yes	 No Has the person making the referral notified the child’s parent/representative?
 By checking this box, I understand I am required to include Specialist records and an active treatment plan. 	
Name of Person or Agency Making Referral: 
     	Phone Number: