I am the treating physician for			
	                 Member Name	            Member Date of Birth	

	who has been diagnosed with End-Stage Renal Disease (ESRD).	
    AHCCCS ID #		

It is my opinion that in the absence of the following dialysis treatments at least three times per week, the member’s ESRD would reasonably be expected to result in:
a.	Placing the member’s health in serious jeopardy, 
b.	Serious impairment of bodily function, or
c.	Serious dysfunction of a bodily organ or part.

It is my medical opinion that		requires		Dialysis treatments per week.	
	   Member Name				

Signature	Date	
		
Provider Name	AHCCCS Provider ID #	

Dialysis Start Date

Dialysis Facility		

SUBMIT THIS FORM TO AHCCCS/DFSM FOR ALL NEW DIALYSIS PATIENTS
FAX: (602) 256-6591	

The FFS PA request form shall be used as the fax coversheet.
For questions call AHCCCS Provider Services at: 602-417-7670